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1 FINAL REPORT Mapping of tools on HIV-related stigma and discrimination in health care settings 5 December, 2015
Transcript of FINAL REPORT - teampata.orgteampata.org/wp-content/uploads/2017/06/Mapping-of... · FINAL REPORT...
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FINAL REPORT
Mapping of tools on HIV-related stigma and discrimination in
health care settings
5 December, 2015
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Table of Contents
Acknowledgements .................................................................................................................................. 3
Introduction ............................................................................................................................................... 4
Background ................................................................................................................................................ 4 Understanding stigma and discrimination.............................................................................................. 5
Methods ..................................................................................................................................................... 8 Scope ..................................................................................................................................................................... 9
Findings....................................................................................................................................................... 9 Response rates ................................................................................................................................................ 10 Overview of tools identified ....................................................................................................................... 10 Audiences and settings ................................................................................................................................ 11 Uptake of tools ................................................................................................................................................ 13 Content of the tools – stigma, discrimination or both ...................................................................... 14
Overview ......................................................................................................................................................................... 14 Tools that primarily address stigma ................................................................................................................... 14 Tools that primarily address discrimination ................................................................................................... 16
Strengths and successes .............................................................................................................................. 17 Challenges......................................................................................................................................................... 18
Moving forward ...................................................................................................................................... 19 Emerging gaps ................................................................................................................................................. 20 Possible avenues for action ........................................................................................................................ 20
Discrimination as an entry point .......................................................................................................................... 20 Discrimination against whom? .............................................................................................................................. 21 Action within the health care setting .................................................................................................................. 22 Actions outside health care settings ................................................................................................................... 23 Format of new tools ................................................................................................................................................... 24
Conclusion ................................................................................................................................................ 24
Annex 1 – Online questionnaire ........................................................................................................... 26
Annex 2 – Inventory of Tools ................................................................................................................ 29
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Acknowledgements
UNAIDS would like to acknowledge the time and expertise of the experts who contributed the
development of this report, led by Laura Ferguson at the Program on Global Health and Human
Rights, Institute for Global Health, University of Southern California.
This report has been developed in the frame of the H4+ project.
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Introduction There is increasing acknowledgment of the need to address stigma and discrimination,
including in health care settings. The 2030 Agenda for Sustainable Development commits
member states to achieving a world of universal respect for equality and non-
discrimination”, and “to leave no one behind”.1 The UNAIDS Strategy 2016-2021 has a clear
target on eliminating HIV-related discrimination with a particular focus on health care.2 A
key milestone in 2015 was the launch of the “zero discrimination” targets, which are
expected to galvanize progress towards ending discrimination and offer a framework for
accountability in this key area. One of those targets relates to eliminating discrimination in
all settings, with a particular focus on healthcare. Furthermore, WHO’s draft Global
Strategy for Human Resources for Health also prioritizes ending discrimination in
healthcare settings.3
UNAIDS commissioned a mapping of existing tools on HIV-related stigma and
discrimination in health care settings, with a view to identifying potential gaps in the
available tools where additional tools might be needed to accelerate progress towards
these global targets.
There were two objectives to this mapping exercise:
• To map existing tools on HIV-related stigma and discrimination in health
care settings; and
• To assess uptake of tools and perceptions of strengths, weaknesses and gaps.
This report presents the finding of the mapping exercise. Relevant background information
is provided, including some detail on the differences between stigma and discrimination as
these are important to the analyses that have been carried out. Following a brief section on
the methods used for this research, the findings are presented, which leads into a section
on ‘moving forward’ that seeks to outline opportunities for advancing work in this area.
Background
1 United Nations General Assembly. (2015) Transforming our world: the 2030 Agenda for 12 Sustainable
Development. A/RES/70/1. New York, USA, United Nations. https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf
2 UNAIDS. (2015) UNAIDS 2016-2021 Strategy: On the Fast-Track to end AIDS. Geneva, Switzerland, UNAIDS. http://www.unaids.org/sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf
3 WHO. (2015) Global Strategy for Human Resources for Health: Workforce 2030. Draft for Consultation. Geneva, Switzerland, WHO. http://www.who.int/hrh/resources/glob-strat-hrh_workforce2030.pdf?ua=1
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HIV-related stigma and discrimination in health care settings are known to negatively
affect the HIV response. Experiences of HIV-related stigma and discrimination have been
widely reported in health care settings around the world and have constituted a deterrent
to accessing HIV-related and other health services. Stigma and discrimination in health care
settings takes many forms including the denial of health care and unjust barriers to service
provision, inferior quality of care and a lack of respect. They also encompass abuse and
other forms of mistreatment, violation of physical autonomy, mandatory testing or
treatment and compulsory detention.4 Health workers living with HIV can also experience
stigma and discrimination within their workplace.
Understanding stigma and discrimination
It is important to have a clear understanding of the definitions of stigma and discrimination
in order that their similarities and differences can be understood. UNAIDS has provided
useful definitions that are consistent with international standards and of particular
relevance to HIV.
Stigma is derived from a Greek word meaning a mark or stain, and it refers to beliefs
and/or attitudes. Stigma can be described as a dynamic process of devaluation that
significantly discredits an individual in the eyes of others, such as when certain attributes
are seized upon within particular cultures or settings and defined as discreditable or
unworthy.5
Fear of stigmatization may lead some people to avoid HIV testing, which could lead to
inadvertent HIV transmission, as well as delays in initiation of treatment and coping
difficulties for those who have been tested and are HIV-positive. Additionally, stigma can
contribute to mental health difficulties, including depressive symptoms, and is associated
with poorer health behavior adaptation and treatment adherence.6
When stigma is acted upon, the result is discrimination; however, discrimination is broader
than manifestations of stigmatizing attitudes.
4 UNAIDS. (2015) Catalysing Global Action to Eliminate Stigma and Discrimination in Health Care. Geneva, 10
- 11 November 2015: Meeting Statement. Geneva, Switzerland, UNAIDS. 5 UNAIDS. (2015) UNAIDS Terminology Guidelines. Geneva, Switzerland, UNAIDS.
http://www.unaids.org/sites/default/files/media_asset/2015_terminology_guidelines_en.pdf 6 Vanable, P. A., Carey, M. P., Blair, D. C., & Littlewood, R. A. (2006). Impact of HIV-Related Stigma on Health
Behaviors and Psychological Adjustment Among HIV-Positive Men and Women. AIDS and Behavior, 10(5), 473–482. http://doi.org/10.1007/s10461-006-9099-1 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2566551/
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Discrimination refers to any form of arbitrary distinction, exclusion or restriction affecting
a person, usually (but not only) because of an inherent personal characteristic or perceived
membership of a particular group. It is a human rights violation. In the case of HIV,
discrimination can be based on a person’s confirmed or suspected HIV-positive status,
irrespective of whether or not there is any justification for these measures.7
Discrimination can be conceived of as taking two primary forms:
Direct discrimination “may be defined as less favorable or detrimental treatment of an
individual or group of individuals on the basis of a prohibited characteristic or ground such
as race, sex or disability,” or, in certain circumstances, health status.8 Direct discrimination
can occur in a health care setting. For example, a health care provider may not provide
needed services to someone living with HIV because of that person’s HIV status. Unless
justified (e.g. the treatment sought is medically counter indicated), this may constitute a
human rights violation. Often, discrimination may not be this clear cut; it may take the form
of longer wait times, excessive precautions, or other concrete differences in treatment due
to an individual’s health status.
Indirect discrimination “occurs when a practice, rule, requirement or condition is neutral on
its face but impacts disproportionately upon particular groups, unless that practice, rule,
requirement or condition is justified. Prohibitions of indirect discrimination require a state
to take account of relevant differences between groups.”9 Indirect discrimination also
occurs in health care settings. For example, a policy requiring that all clients present an
identity card or birth certificate to access health services may indirectly discriminate
against people living in remote areas who may find it harder to get these documents.
Seemingly neutral laws that amount to discrimination can also constitute violations of
human rights. In this way, existing laws, policies and practices can institutionalize
discrimination, but they can also be vital areas for addressing discrimination. Just as states
have an obligation to address direct discrimination, they also have an obligation to address
indirect discrimination, which may require different treatment of groups—including
remedial measures to remedy past or present systemic discrimination.
7 UNAIDS. (2015) UNAIDS Terminology Guidelines. Geneva, Switzerland, UNAIDS.
http://www.unaids.org/sites/default/files/media_asset/2015_terminology_guidelines_en.pdf 8 The International Centre for the Legal Protection of Human Rights (INTERIGHTS). (2011) Non-
Discrimination in International Law: A Handbook for Practitioners. http://www.interights.org/document/153/index.html (p. 18)
9 Ibid.
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Non-discrimination laws are rooted in equality and universal human rights principles;
moreover, their application to the provision of health services provides another lever for
improving public health. Often, the most directly applicable non-discrimination law or
policy in place will be specific to a country context. In addition, the weight of regional,
international, and universal human rights principles aligns against discrimination in law or
practice. Particularly when combined with compelling public health data, the takeaway is
clear: discrimination in the context of health care is harmful, and steps should be taken to
remedy it in accordance with human rights obligations.
The fundamental principles of equality and non-discrimination form the cornerstone of
international human rights law. They are included among the core purposes of the United
Nations, in which each member state accepts obligations in “promoting and encouraging
respect for human rights and for fundamental freedoms for all without distinction as to
race, sex, language, or religion.”10 These principles have been reiterated and expanded
upon in several sources of international law, including core human rights treaties, and in
regional and domestic law in myriad settings.
Often, discrimination “is linked to the marginalization of specific population groups and is
generally at the root of fundamental structural inequalities in society. This, in turn, may
make these groups more vulnerable to poverty and ill health. Not surprisingly, traditionally
discriminated and marginalized groups often bear a disproportionate share of health
problems. For example, in some societies, ethnic minority groups and indigenous peoples
enjoy fewer health services, receive less health information and are less likely to have
adequate housing and safe drinking water, and their children have a higher mortality rate
and suffer more severe malnutrition than the general population.”11 Further, discrimination
often has a compounded effect, as individuals may face discrimination for multiple reasons,
e.g. race, socioeconomic status and health status, each of which can have disproportionate
impacts on the same marginalized groups.12
Making this specific to HIV, HIV-related stigma and discrimination can extend to “groups
associated with people living with HIV (e.g. the families of people living with HIV) and
other key populations at higher risk of HIV infection, such as people who inject drugs, sex
workers, men who have sex with men and transgender people” as well as people in prisons
10 United Nations. (1945) Charter of the United Nations. New York, USA, United Nations.
http://www.un.org/en/sections/un-charter/chapter-i/index.html (Art. 1 Para. 3) 11 OHCHR & WHO. (N.d.) The right to health. Factsheet No. 31. Geneva, Switzerland, United Nations.
http://www.ohchr.org/Documents/Publications/Factsheet31.pdf 12 Ibid.
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and other closed settings, young people, migrants, and internally displaced people.13 This
intersectionality and layering of stigma and/or discrimination can have particularly
detrimental impacts on health status and access to services.
While complete separation of stigma and discrimination is impossible, each provides a
different, complementary, entry point for work that might address both areas, and
understanding their differences is critical to ensuring that interventions appropriately
specify, assess and address each construct.
Methods
To gain an understanding of existing tools on HIV-related stigma and discrimination in
health care settings, five activities were carried out: internet searches to identify existing
tools; an online survey; key informant interviews; participation at an expert meeting on
‘Catalyzing Global Action to Eliminate Discrimination in Health Care’; and a review of tools.
Each of these is explained in further detail below.
Internet searches: Initial searches were carried out using various combinations of the
following search terms in Google: tool, stigma, discrimination, HIV, health care, health
facility. Websites of NGOs, multilateral agencies and universities known to be doing
relevant work were also searched (both by using search terms and by manually searching).
Online survey: A short questionnaire was designed to elicit information about relevant
tools that are in use. The questionnaire sought to determine what tools were being used,
how users felt about the different tools and if people thought that additional tools might be
useful to their work relating to stigma and discrimination in health care settings. The
questionnaire was administered through Surveymonkey in Arabic, English, Russian and
Spanish. The surveys were posted for six weeks during October – November 2015. Links to
the survey were distributed through listservs, UNAIDS regional offices and to key
informants. See Annex 1 for the English version of the online questionnaire.
Key informant interviews: Preliminary research identified specific individuals whose work
is particularly prominent in the field of HIV-related stigma and discrimination in health
care settings. Semi-structured interviews were carried out with some of these key
informants. Participants were asked about their experiences working in this field, the tools
13 UNAIDS. (2014) Reduction in HIV-related stigma and discrimination: Guidance note. Geneva, Switzerland,
UNAIDS. http://www.unaids.org/sites/default/files/media_asset/2014unaidsguidancenote_stigma_en.pdf
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they have developed and/or used, and if/where they see the need for additional tools.
Interviews lasted for 45-75 minutes, each tailored to the specific expertise of the
participant.
Expert meeting: UNAIDS and the Global Health Workforce Alliance jointly hosted an expert
meeting in Geneva on November 10 and 11 entitled ‘Catalysing Global Action to Eliminate
Stigma and Discrimination in Health Care’. The meeting aimed to define the need for action
and provide an opportunity to establish and further clarify the goals, objectives, and
parameters of future actions. Participants from across the world represented different
types of organizations ranging from grassroots NGOs to inter-governmental agencies; they
spoke about their experiences working to eliminate stigma and discrimination in health
care. Preliminary findings from this research were presented and meeting participants
were asked to share any additional tools that they thought should be included in the
mapping.
Document review: The content of all of the tools identified through carrying out the
previously described activities was analyzed to assess how HIV-related stigma and
discrimination in health care settings were addressed. A data extraction matrix was used to
ensure that information was systematically recorded across all documents e.g. on the
format of the tool, the intended audience, the methodology for implementation. This
information helped to identify the most relevant tools that required a more in-depth
analysis, which forms the basis of this report. An inventory of the most relevant tools
reviewed is presented in Annex 2.
Scope
Tools not relating to HIV or key populations were excluded as they fell outside the scope of
this mapping exercise. However, in developing new tools, valuable lessons may be learned
from some of these tools.
Findings This section presents the findings of the mapping exercise. Following a summary of the
questionnaire and interview response rates, an overview of the tools is provided. Details
are then presented on the settings and audiences for which existing tools have been
designed as well as on the levels of uptake of some of the most frequently used tools.
Analysis of key content is divided into tools that primarily address stigma and those that
primarily address discrimination. Successes and challenges of work to date are briefly
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discussed before a forward-looking section that aims to identify potential gaps in existing
tools and useful avenues for effectively moving forward work to address HIV-related
stigma and discrimination in health care settings.
Response rates
There were a total of 151 responses to the online questionnaire. Figure 1 shows the
breakdown of responses by language.
Figure 1: Questionnaire responses by language
Although there was some missing data in a few questionnaires, this was negligible and
there was no pattern in questions that were not answered.
Interviews were carried out with six out of the eight key informants who were invited to
participate. One person who was invited never responded to email requests for an
interview; one person was on extended leave and unable to participate given the timeframe
for the research.
Overview of tools identified
Fifty-nine relevant tools were identified through internet searches, an additional eleven
country-specific tools identified through the questionnaire, eight tools were provided by
key informants, and participants at the expert meeting provided five additional tools for
review. Thus, in total, eighty-three tools were reviewed; sixty-four of which were found to
be relevant and included in this analysis and inventory. Reasons for exclusion included the
document simply providing background information rather than functional utility as a tool,
providing too little information to be deemed relevant, or having a particularly tenuous
connection to assessing or addressing stigma and/or discrimination in health care settings.
Arabic, 9
English, 64 Russian,
33
Spanish, 45
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Most of the tools are specific to health care settings but there are some exceptions where
the research team found that, even as the tools were broader than health care settings,
there were useful lessons to be yielded that might have relevance to addressing HIV-
related stigma and discrimination in these settings.
A range of types of tools was included in this analysis: measurement tools, training
materials, checklists, guidelines, guidance notes and reports. Guidelines, guidance notes
and reports could be considered more ‘passive’ tools in that they contain recommendations
for action but they are primarily designed to be read by relevant stakeholders who can
then choose to implement the recommendations. In contrast, the measurement tools,
training materials and checklists all require more active engagement in actions directed by
the tools themselves.
Some of the tools seek to assess HIV-related stigma and/or discrimination in health care
settings while other tools are designed to help address these issues. A few tools, such as
Health Policy Project’s Comprehensive Package for Reducing Stigma and Discrimination in
Health Facilities, do both of these things by starting with an assessment of stigma and
discrimination in the specific context of the health care setting so as to inform how to
prioritize actions to address these issues. No tools were found that included a follow-up
assessment sufficiently long after the initial intervention to assess long-term change in
levels of stigma and discrimination in the health care setting. Tools to address stigma and
discrimination are most often training materials designed to increase awareness of the
issues as well as knowledge and capacity to act in non-stigmatizing and non-discriminatory
ways. As mentioned above, there are also some good practice guides and case study
publications designed for self-directed learning to improve behaviours.
Audiences and settings
The currently available tools are designed for many different users – researchers, trainers,
health care workers, health managers, community-based organizations etc. – and are
designed to be implemented with a range of different stakeholders responsible for
addressing stigma and discrimination within health care settings – health workers, health
managers, lawyers, national-level government officials etc. For example, some tools are
designed for use by researchers to assess the attitudes of health facility staff around HIV;
other tools are meant to be used by trainers and key population representatives to build
health worker capacity to provide health services that do not stigmatize or discriminate
against people living with HIV and other key populations. One of the most common
audiences for the tools reviewed was trainers or facilitators: training materials were
provided for someone skilled in training to use with health workers or other groups. The
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reports and guidelines contain useful recommendations or guidance for action, most of
which are designed for a broad audience of policy-makers, programme managers, health
workers etc.
Questionnaire respondents were asked to identify gaps in audiences and settings targeted
by existing tools; the findings are presented in Table 1.
Table 1: Number of respondents who identified specific gaps in audiences and settings targeted by existing tools
Where perceived gaps exist
Number of
respondents
Audience
General health worker 41
Doctors and/or clinical officer 33
Nurses, midwives, nurse
assistants 28
Community health workers 28
Managers 24
Other non-medical 28
Settings
General health care setting 39
Hospitals 38
Health centres 31
Community-based health services 38
As evidenced in the table above, no clear patterns emerged about specific settings or
audiences that were either well-covered by current tools or where additional tools are
particularly needed. From the review, no tools were found that specifically target
community health workers. Some tools target health service providers while others were
designed to be used more broadly e.g. with all staff within a health facility including
managers, administrators and other support staff in addition to health workers.
Similarly, no tools were found that were specific to hospitals or community-based health
services; most tools for use within health care settings were targeted to ‘health facilities’
generically. Furthermore, the tools seemed to target the entire health facility without any
particular focus on a specific set of services within the facility.
In addition to the audiences and settings covered above, other areas where additional tools
might be required were identified through our analysis of existing tools. These included
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tools for working with civil society and tools for building the capacity of other stakeholders
whose actions also affect stigma and discrimination in health care settings such as the
judiciary, policy-makers etc. The review did include some tools for building the capacity of
rights-holders to claim their rights relating to non-discrimination in health care settings
(e.g. Positive Protection! Empowering Women Affected by HIV to Protect their Rights at
Health Care Settings) but these tools were all more broadly about health-related rights than
focused on discrimination.14
Uptake of tools
Table 2 below shows the tools that were most frequently mentioned by questionnaire
respondents. It is important to note that by disseminating the questionnaire through
UNAIDS regional offices, among other dissemination modalities, there may have been a
disproportionate number of UNAIDS staff/partners among respondents, which may explain
why the UNAIDS Guidance Note is the most often-mentioned tool.
Table 2: Tools that were most frequently mentioned by questionnaire respondents
Tool Number
of times
mentioned
Reduction of HIV-related stigma and discrimination: Guidance note (UNAIDS) 31
Comprehensive package for reducing stigma and discrimination in health facilities
(HPP)
15
Sexual and Reproductive Health of Women and Girls Living with HIV: Guidance of
health managers, health workers and activists (Engender Health, UNFPA, Packard)
10
Reducing stigma and discrimination related to HIV and AIDS: Training for health
care workers (Engender Health)
7
Understanding and challenging HIV stigma: Toolkit for action (ICRW) 6
Sexual minorities, human rights and HIV/AIDS: A trainer's guide (BONELA) 5
The time has come (UNDP Asia Pacific) 4
14
The primary focus of this review is discrimination in health care settings, which is one of
many health-related rights. The tools designed to build rights-holders capacity to claim their
rights all cover a broader range of relevant rights such as the rights to health, privacy and
information in addition to issues around equality and non-discrimination.
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Content of the tools – stigma, discrimination or both
Overview
In the online questionnaire, respondents were asked if each tool they mentioned covered
stigma, discrimination or both. People responded overwhelmingly that the vast majority of
tools covered both stigma and discrimination (Figure 2).
Figure 2: Number of tools that cover stigma, discrimination and both of these
However, our analysis of the tools revealed a very different picture: almost without
exception, tools use stigma as their entry point – targeting people’s attitudes, societal
drivers of stigma etc. – and discrimination is addressed only as a manifestation of stigma.
There appears to be an underlying assumption that stigma is the attitude that underlies
behaviours that might constitute discrimination and therefore by changing the attitudes
the behaviours should change. Very few tools are rooted in international human rights or a
legal definition of non-discrimination, and use this as the starting point for action.
Tools that primarily address stigma
There are some excellent tools for addressing HIV-related stigma within health care
settings, including some tools specifically designed for this purpose. In other tools,
attention is given to stigma in settings beyond (but including) health care, and in some
cases the tools are country-, region- or population-specific. Across the available tools,
different types of stigma (e.g. anticipated stigma, internalized stigma, experienced stigma
etc.) are all covered as well as the layering of stigma (e.g. relating to HIV-status, race, same-
sex sexual behaviours etc.) that an individual can experience.
Health Policy Project’s Comprehensive Package for Reducing Stigma and Discrimination in
Health Facilities comprises three separate documents: a standardized questionnaire for
Stigma, 15 Discrimin
ation, 17
Both, 127
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measuring HIV stigma and discrimination among health facility staff, a facilitator’s training
guide for a stigma-free health facility, and a resource guide for administrators for achieving
stigma-free health facilities and HIV services.15 It was published in 2015 following
extensive validation and it is a useful set of tools. Although its overarching title suggests
that it addresses both stigma and discrimination, discussion of the latter is mostly limited
to discrimination as a manifestation of stigma. This is reflected in the names of two of the
individual tools that include only ‘stigma’ and not ‘discrimination’. However, much of what
is called ‘stigma’ within some of the documents in this package of tools actually constitutes
discrimination. Examples include health workers delaying or refusing treatment to certain
clients, using excessive precautions (e.g. multiple pairs of protective gloves) or other
differential treatment. Although not legally grounded or called ‘discrimination’ there are
useful materials relating to these topics that could be adapted for use in addressing
discrimination explicitly.
The People Living with HIV Stigma Index published by ICW, GNP+ and UNAIDS is a widely
used tool to assess levels of stigma experienced by people living with HIV.16 It also
encompasses some attention to experiences of discrimination as manifestations of the
stigmatizing beliefs of others, in settings as health care, workplace, education, communities
among others It is a comprehensive index that goes beyond health care settings to assess
stigma across different contexts, including in health care settings, workplaces, educational
settings and communities.
As mentioned above, other tools are far more focused targeting specific populations within
a single country. Addressing Stigma: A blueprint for improving HIV/STD prevention and care
outcomes for black and latino gay men is an example of a US-focused tool that is specifically
tailored for black and latino gay men but it retains some breadth in seeking to address
stigma broadly i.e. within but also beyond health care settings.17 A handful of other
country-/region- and population-specific tools were also reviewed, many of which,
including a series of tools published by ICRW and partners as part of their Understanding
and Challenging Stigma series, focused on key populations in Asia.
15 Health Policy Project. (2015) Comprehensive Package for Reducing Stigma and Discrimination in Health Facilities. http://www.healthpolicyproject.com/index.cfm?id=stigmapackage 16 ICW, GNP+, UNAIDS. (2015) People living with HIV stigma index. http://stigmaindex.org/ 17 National Alliance of State and Territorial AIDS Directors (NASTAD). (2014) Addressing Stigma: A blueprint for improving HIV/STD prevention and care outcomes for black and latino gay men. https://www.nastad.org/sites/default/files/NASTAD-NCSD-Report-Addressing-Stigma-May-2014.pdf
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Tools that primarily address discrimination
Some legally grounded tools that specifically address discrimination were identified but
none of the questionnaire respondents mentioned any of these tools suggesting that they
are not widely used by health/HIV professionals. It may be that the law and human rights
community more actively uses these tools.
Where human rights (including the right to non-discrimination) were explicitly part of
tools, a ‘violations approach’ was usually used, which focuses on when human rights are
violated and how to access mechanisms to seek redress for the violations that have
occurred. Dealing with problems and Virtual Office of Human Rights and Legal Services,
although essentially both just web pages and more broadly focused than just health care
settings, are examples of useful tools for helping people respond to any discrimination they
think they have experienced i.e. how to complain, seek mediation or make a claim in
court.18 Another tool that addresses human rights violations is the International HIV/AIDS
Alliance’s Rights – Evidence – ACTion (REACT) tool.19 REACT is a community-based system
for monitoring and responding to human rights-related barriers in accessing HIV and
health services. Its focus is linking victims of human rights violations to support services
but it also systematically documents relevant rights violations to inform policy change and
legal reform efforts.
No tools were found that helped support people working in a health care setting to
understand their human rights obligations as duty bearers and develop their capacity to
fulfill these obligations. OSF’s Template for “Human Rights in Patient Care, A Practitioner
Guide” provides a framework of topics that should be covered in training lawyers to
improve the realization of human rights within health care settings; lessons could usefully
be drawn from this approach and targeted towards staff working in health care settings.20
The Blueprint for the provision of comprehensive care for trans people and trans communities
in Asia and the Pacific provides comprehensive information relating to discrimination
against transgender people in the region, including within health care settings.21 Within the
18 NAM. (n.d.) Dealing with problems. http://www.aidsmap.com/Dealing-with-problems/page/1501232/ Letra Ese. (n.d.) Virtual Office of Human Rights and Legal Services. http://www.letraese.org.mx/proyectos/proyecto-2/ 19 International HIV/AIDS Alliance. (2015) Rights – Evidence – ACTion (REAct) Guide. http://www.aidsalliance.org/assets/000/001/310/REAct_User_Guide_original.pdf?1424259862 20 Open Society Foundations. (2009) Template for “Human Rights in Patient Care, A Practitioner Guide”. http://www.health-rights.org/guides/pginto/ 21 United Nations Development Programme (UNDP), Asia Pacific Transgender Network (APTN) and Health Policy Project (HPP). (2015) Blueprint for the provision of comprehensive care for trans people and trans
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report, there are simple tips for improving health services for transgender individuals
including lists of ‘positive things’ health workers can do. This is a useful example of simple,
targeted information, framed constructively, that could make a practical difference within
health care settings.
Some tools differentiate between discrimination that is legally actionable and
discrimination that is not, while in one instance a distinction was made between
‘Experienced stigma (outside legal purview)’ and ‘Discrimination (inside legal purview)’.
This highlights the need to ensure clear definition of both stigma and discrimination in any
tools relevant to this area. Current conflation of terms has led to some confusion about
their differences; the importance of the specificity and precision of language cannot be
overstated.
Strengths and successes
A variety of good practices emerged from the analysis of existing tools ranging from how
they were developed to processes of implementation. Ensuring a participatory process of
tool development followed by rigorous testing and validation of the tools helped ensure the
relevance, practicality and acceptability of many of the tools reviewed. Ensuring that PLHIV
played a central role throughout these processes has empowered communities of PLHIV
across different settings.
The importance of identifying and collaborating with ‘champions’ who can help drive work
on HIV-related stigma and discrimination in health care settings is key. This may include
people working at the health facility level, community members, civil society organizations
or national-level government officials. These ‘champions’ can help promote
institutionalization and sustainability of efforts to reduce stigma and discrimination. This
was clearly seen in China where the government was mobilized to include transgender
needs in the new national HIV strategic plan following implementation of Asia Catalyst’s
Know It, Prove It, Change It: A Rights Curriculum For Grassroots Groups tool, and in Thailand
where the government institutionalized stigma and discrimination reduction activities
following use of the Comprehensive Package for Reducing Stigma and Discrimination in
communities in Asia and the Pacific. http://www.asia-pacific.undp.org/content/rbap/en/home/library/democratic_governance/hiv_aids/blueprint-for-the-provision-of-comprehensive-care-for-trans-peop.html
18
Health Facilities.22 One final example of institutionalizing attention to HIV-related stigma
and discrimination can be seen in the use of the REACT tool, which has been used as a
resource for the integration of human rights programmes in Global Fund applications in
over ten countries.23
Fostering strong links with communities and community-based organizations can help
ensure follow-up and promote accountability. Furthermore, ensuring a multi-stakeholder
approach (including government and civil society actors) can allow for joint mobilization to
identify human rights issues in the HIV response and align collectively around priorities to
address them. This has been seen in countries where UNDP’s Practical Manual: Legal
Environment Assessment for HIV, An operational guide to conducting national legal,
regulatory and policy assessments for HIV tool has been used.24
Challenges
Despite the strengths of existing tools and the many successes recorded to date, challenges
persist in this area of work.
Although most of the tools that seek to reduce HIV-related stigma and/or discrimination in
health care settings are training materials designed for use with health facility staff, most
informants of this research noted that one-off training is insufficient for effecting change.
Alternative methods for building capacity such as online platforms and apps for use with
mobile technologies are, to our knowledge, not currently being used for work in this area
but would be useful to explore.
Users of existing tools complained that most of the tools were not comprehensive, which
they saw as a weakness. However, at the same time, questionnaire respondents stated that
the tools were too long and time-consuming. Many of the tools are designed with flexibility
in mind so that the length of training can be tailored to the time available, but the challenge
remains of how to ensure training that is sufficiently ‘comprehensive’ without it being too
22
Asia Catalyst, Thai AIDS Treatment Action Group (TTAG) and Dongjen Center for Human Rights Education
and Action. (n.d.) Know It, Prove It, Change It: A Rights Curriculum For Grassroots Groups. http://asiacatalyst.org/resources/cbo-resources/ 22 Health Policy Project. (2015) Comprehensive Package for Reducing Stigma and Discrimination in Health Facilities. http://www.healthpolicyproject.com/index.cfm?id=stigmapackage 23 International HIV/AIDS Alliance. (2015) Rights – Evidence – ACTion (REAct) Guide. http://www.aidsalliance.org/assets/000/001/310/REAct_User_Guide_original.pdf?1424259862 24 UNDP. (2014) Practical Manual: Legal Environment Assessment for HIV, An operational guide to conducting national legal, regulatory and policy assessments for HIV. http://www.undp.org/content/undp/en/home/librarypage/hiv-aids/practical-manual--legal-environment-assessment-for-hiv--an-opera.html
19
long. Questionnaire respondents and key informants alike underscored the need for simple
tools that are easy to implement: long and complicated processes of implementation
deterred people from using some tools at all.
Demand on health workers’ time is high, with regard to both clinical work and required on-
the-job training. For health workers (and other health facility staff) to prioritize work to
reduce HIV-related stigma and discrimination in health care settings, it will be important to
increase understanding of why this is a critical part of an effective HIV response, perhaps
underlining the growing number of global-level commitments in this area.
One approach that FHI360 is currently working on is developing tools of ‘top ten things to
change’ within health facilities that would make a difference for specific key populations
e.g. young MSM clients. They hope that by disseminating very targeted, practical messages
encompassing good practices in clinical care as well as the general experience of client care
for key populations, they might effective positive change. However, the modality for any
training that would accompany these messages is not yet clear.
There already exists a great number of tools designed to assess or address at least some
aspects of stigma and/or discrimination in health care settings, yet knowledge and uptake
of most of the tools appears to be low. It is important that potential users know what tools
are available to them, what each one is designed to achieve and how they might be
implemented. At the same time, strategic use of the tools is required to ensure that efforts
are complementary and coherent so as to maximize gain from any tools implemented and
to minimize duplication of efforts. Insufficient funding for this work has meant that existing
tools are not used as much as they might be and that few tools have been rigorously
evaluated.
Out of the 54 questionnaire respondents who stated that they or their institution had
created tools on HIV-related stigma and discrimination within health care settings, only 13
(24%) had evaluated these tools. Furthermore, of the 54 respondents who stated that they
used tools created by others, only four (7%) stated that they knew of any evaluations of the
tools they were using. The lack of evaluation of existing tools limits our ability to
understand which approaches might be most effective at addressing HIV-related stigma
and discrimination in health care settings moving forward.
Moving forward
20
Emerging gaps
General consensus existed among research participants that insufficient tools exist for
addressing stigma and discrimination within health care settings, and that additional tools
would help accelerate action in this area: 71% of questionnaire respondents noted the
need for additional tools.
There are clear gaps in the existing tools on eliminating discrimination in health care
settings as most of them focus predominantly on stigma. In current tools there is very
limited focus on ensuring that everyone in a health care setting understands and can fulfil
their legal obligations with regard to non-discrimination or on the creation of an enabling
legal and policy environment for non-discriminatory health care. Efforts to empower clients
to claim their rights in the context of health care may also need to be taken to scale.
Another noticeable gap with regard to work carried out to date is in the evaluation of
efforts to reduce HIV-related stigma and discrimination in health care settings. Moving
forward, funding should be allocated to ensuring that rigorous evaluation can be carried
out to ascertain which approaches to this work are most effective.
Possible avenues for action
Discrimination as an entry point
In many places, health workers appear receptive to understanding more about human
rights and the legal and policy environment as a way of strengthening their work. This is
likely particularly true if a supportive approach can be adopted whereby tools aim to help
relevant duty-bearers fulfil their human rights obligations rather than naming and shaming
them for rights violations. This approach can strengthen work to understand the drivers of
stigma that lead to discrimination within health care settings by providing an additional
angle from which to approach the issues in the context of health and human rights
accountability.
Stigma and discrimination, although strongly inter-related, provide different,
complementary entry points for work that might address both areas. However, using the
framework of legal obligations that is linked to the human rights principle of non-
discrimination can draw attention to the types of actions that constitute discrimination,
highlight that such actions constitute human rights violations, and help health workers and
other duty bearers to fulfil their legal obligations with regard to non-discrimination. It can
also identify where legal and policy environments provide useful protections against
discrimination as well as where they might need to be strengthened to ensure that
21
adequate protection can be provided. It is critical that the ‘value added’ of using
discrimination as an entry point be explicit in any future tools that take this approach.
In thinking about addressing discrimination in health care settings, there are many useful
tools from which lessons can usefully drawn. Furthermore, there are useful pieces within
existing tools, some of which, with permission, could be included in additional tools going
forward. For example, OSF’s Practitioners Guides in Law and Health are squarely grounded
in the human rights notion of non-discrimination but no clear methodology for
implementation is outlined.25 Conversely, the methodology of the Comprehensive Package
for Reducing Stigma and Discrimination in Health Facilities is very well-developed but the
content is not explicitly grounded in a human rights or legal definition of non-
discrimination.26 The content from these guides could usefully inform targeted tools for
addressing discrimination in health care settings.
Discrimination against whom?
The tools in this mapping relate to stigma and discrimination against a range of different
populations including people living with HIV, women and girls, men who have sex with
men, transgender people, drug users and sex workers. Some tools focus on a single one of
these populations while a few tools seek to cover multiple different populations. This can
prove challenging if the scope of the tool is broad in other ways (e.g. encompassing settings
beyond health care). However, if the scope of a tool were limited to discrimination within
health care settings it would seem feasible to address discrimination broadly
encompassing attention to all population groups and addressing intersectionality of
discrimination.
At the same time it is also key that health workers and others working within health care
settings understand that they themselves may be subject to discrimination and that they
are rights-holders in this regard as well as duty-bearers. Any tool should encompass
attention to discrimination against people working within health care settings to ensure
that they feel subject to protection, rather than simply being targeted as potential
perpetrators of discriminatory actions.
25 Open Society Foundations. (2009) Template for “Human Rights in Patient Care, A Practitioner Guide”. http://www.health-rights.org/guides/pginto/ 26 Health Policy Project. (2015) Comprehensive Package for Reducing Stigma and Discrimination in Health Facilities. http://www.healthpolicyproject.com/index.cfm?id=stigmapackage
22
Action within the health care setting
As with other actions to advance health, different levels need to be considered with regard
to ensuring non-discrimination: the level of care the facility is equipped to provide (with
particular relevance to ensuring that health workers have access to adequate supplies to
ensure universal precautions); the level of care the structure/system is ready to provide
(relevant laws and policies); the level of care providers are offering to clients (reflecting
providers’ attitudes and behaviours); and clients’ experience of care. The PLHA-friendly
checklist, although its content is much broader than discrimination, has a useful breakdown
of sub-domains across which action is required: Practice (practices and behaviours of
staff), Training (building and maintaining the capacity of the staff to practice these
standards), Quality Assurance (institutional mechanisms to monitor and ensure practice of
gold standards), and Policy (institutional rules and regulations stipulating or enforcing the
gold standards).27 Attention to the regulatory framework at health facility level, including
policies, their implementation, and penalties for infractions, is an area that seems
particularly under-explored to date. Perhaps with the addition of the national and sub-
national legal and policy environment (as assessed by UNDP’s Practical Manual: Legal
Environment Assessment for HIV, An operational guide to conducting national legal,
regulatory and policy assessments for HIV tool for example28), these four ‘sub-domains’
might be a useful framework for considering actions to address discrimination within
health care settings.
Many different jobs exist within health care settings and although no clear consensus
emerged from the online questionnaire regarding which cadres most lack tools for
addressing HIV-related stigma and discrimination, it would seem critical that attention to
all staff be incorporated in any tools. A patient’s experience of visiting a health care setting
is shaped by all interactions that occur there. It is often non-clinical staff (e.g. receptionists,
janitors) who display discriminatory behavior and they should therefore be included in any
efforts to reduce HIV-related discrimination in these settings. Attention to the knowledge
and behaviours of health workers in all parts of the health care setting may also be
necessary – sometimes health workers in HIV services are targeted for training while much
discrimination occurs in non-HIV-specific services.
27 Horizons Project/Population Council and SHARAN. (2005) The PLHA Friendly Checklist: A Self Assessment Tool for Hospitals and Other Medical Institutions Caring for People Living with HIV/AIDS. http://www.popcouncil.org/uploads/pdfs/horizons/pfechklst.pdf 28 UNDP. (2014) Practical Manual: Legal Environment Assessment for HIV, An operational guide to conducting national legal, regulatory and policy assessments for HIV. http://www.undp.org/content/undp/en/home/librarypage/hiv-aids/practical-manual--legal-environment-assessment-for-hiv--an-opera.html
23
Although a few respondents suggested that health workers had reasonable knowledge of
relevant laws and policies, most respondents thought that this knowledge was low. There
was agreement among respondents that even where laws were clear, grey areas still arose
in practice where health workers wanted additional guidance e.g. what to do if a man who
has sex with men presents for health services in places where same-sex sexual behaviour is
illegal. There appears to be a need to increase knowledge of relevant laws and policies
alongside providing practical guidance on how best to provide services to all populations,
including those whose behaviours might be criminalized.
Actions outside health care settings
While it is indeed within health care settings that work is required to ensure non-
discrimination in these settings, such actions might be limited by broader structural issues
including the legal and policy environment as well as health systems constraints. Ideally,
complementary work could be simultaneously undertaken within health care settings and
at national (and potentially sub-national) level to ensure that the enabling environment is
in place to allow staff in health care settings to fulfill their human rights obligations with
regard to non-discrimination and clients to seek redress should they be discriminated
against in the context of seeking and receiving health care. For example, it may be
necessary to strengthen the health system to ensure that health workers have an
uninterrupted supply of supplies so that they can implement universal precautions; in the
absence of such supplies, health workers might be fearful to treat people living with HIV,
which could lead to discriminatory behaviours. No tools (or toolkit) exist to facilitate this
two-pronged approach to action. Furthermore, this approach would require substantial
political commitment, funding and coordination.
Beyond tools for use within healthcare settings, there is also a clear need to work with
other duty bearers whose roles shape the delivery of health services as well as access to
remedy in the cases of discrimination occurring in healthcare settings. This might include
training the media, judiciary or law enforcement officers to ensure an enabling
environment.
In addition, the use of human rights mechanisms such as the Universal Periodic Review,
treaty-based reporting, and regional and national human rights institutions should be
promoted as additional avenues for strengthening accountability for operationalizing legal
and human rights protections relevant to non-discrimination within healthcare settings.
24
Format of new tools
The paucity of evaluation of existing tools has created a gap in the evidence of which (types
of) tools are most effective at addressing HIV-related stigma and discrimination in health
care settings. However, it is likely that any new toolkit that might be developed should
include a variety of formats of tools. For example, it may be important to: measure the
levels and types of discrimination that are occurring, build stakeholder capacity to
understand and fulfill their obligations with regard to non-discrimination, and have a
checklist within health care settings that staff and clients can readily refer to.
Due to limited funding and project periods, much of the work to date has focused on one-off
capacity building with no follow-up. It is critical that any assessment and training are part
of a broader agenda for action and that new tools try to stimulate local ownership and
institutionalization of actions to reduce HIV-related discrimination in health care settings.
Incorporating capacity building into ongoing pre- and in-service trainings could be an
effective way of institutionalizing this work.
Conclusion
This mapping exercise has identified a large number of tools, albeit of varying quality,
relevant to reducing HIV-related stigma and discrimination in health care settings.
While a plethora of tools already exist that are relevant to this work, many of them are not
specific to this topic: they encompass a much broader range of topics and/or settings.
Furthermore, the tools are not designed to fit together and implementation of tools to date
has been piecemeal, with no documented concurrent use of different tools that were not
specifically designed as a toolkit/package.
Excellent tools exist to cover stigma reduction within health care settings, but no tool exists
that specifically seeks to address HIV-related discrimination within health care settings.
Much excellent work exists to build upon and a tool that specifically addresses HIV-related
discrimination in healthcare settings could be a useful addition.
No single tool could cover the vast topic of HIV-related discrimination in health care
settings but it would be useful to envisage a toolkit encompassing different tools, each
designed to address one aspect of this topic. This could be conceptualized in a range of
different ways and it would be useful to seek the input or potential users on any initial
ideas that emerge from this work.
25
There is an evident tension between the complexity of the issue to be addressed and the
need for simple tools. Rather than trying to target all stakeholders working at all levels
(from community to national government), a series of tools is needed that is designed to fit
together but with each tool targeting a specific element of the required response.
Concerted action by a wide range of stakeholders will be required if the global targets of
‘zero discrimination’ are to be met. For some of these stakeholders, stigma will resonate as
a useful entry point for this work; for others, addressing discrimination from a starting
point of law and human rights will resonate more. The latter is an entry point that has been
under-utilized to date, an area where tools are lacking, and an approach that will constitute
an additional lever for action that could prove critical to reaching global targets and, in so
doing, improving the quality of life of people living with HIV around the world.
26
Annex 1 – Online questionnaire
Part 1 – People/organizations who have created relevant tools
1. Have you and/or your institution created any tools to assess or address HIV-related
stigma or discrimination within health care settings? [Y/N response option]
If yes, please list all of these tools and provide links to access the tools where available so
that we can review each tool and include it in the database of key resources. If you prefer to
email tools to us, please send them to: [email protected] [text box response
option]
If no, skip to question 6.
2. For each of these tools, is the focus on stigma, on discrimination or on both? [text box,
and box to check for each possible response, with 3 sets of boxes (assuming a maximum
of 3 tools per respondent)]
3. Please list up to three examples of results achieved through using your tools, making
clear which achievements resulted from use of which tool. [text box response option]
4. Have any of your tools been evaluated or assessed? If yes, please provide details or a link
to the evaluation report for each one or email it to us
([email protected]). [Y/N response option, with space for additional
text]
5. Are there any changes that you would make to each of your tools to improve their
effectiveness? [text box response option]
Part 2 – People/organizations who use tools created by others
6. Do you or your partners use any tools created by other individuals or organizations to
assess or address HIV-related stigma and discrimination in health care settings? [Y/N
response option]
If yes, continue questions.
If no, skip to question 14.
7. Please tick any of the tools below that you have used and list any additional tools that you
have used. Where available, please also provide links for accessing the additional tools or
email them to us ([email protected]) so that we can review each tool and
include them in the database of key resources. [9 tools listed with check boxes, and text
box response option]
Tools to be listed:
Comprehensive package for reducing stigma and discrimination in health
facilities (Health Policy Project);
Reduction of HIV-related stigma and discrimination: Guidance note (UNAIDS);
Measuring HIV stigma and discrimination: Technical brief (STRIVE, LSHTM,
ICRW);
27
"The Time Has Come" Enhancing HIV, STI and other sexual health services for
MSM and transgender people in Asia and the Pacific: Training package for health
providers to reduce stigma in health care settings (UNDP Asia Pacific);
Sexual minorities, human rights and HIV/AIDS: A trainer’s guide (BONELA);
Sexual and reproductive health of women and adolescent girls living with HIV:
Guidance of health managers, health workers and activists (Engender Health,
UNFPA, Packard);
Taking action against HIV stigma and discrimination (DFID, ICRW);
Reducing stigma and discrimination related to HIV and AIDS: Training for health
care workers (Engender Health); and
Understanding and challenging HIV stigma: Toolkit for action (ICRW).
Other
8. What do you like most about these tools? Why? Please make clear which tool your
comments relate to. [text box response option]
9. What do you like least about these tools? Why? Please make clear which tool your
comments relate to. [text box response option]
10. For each of these tools, is the focus on stigma, on discrimination or on both? [text box
and box to check for each possible response, with 3 sets of boxes (assuming a maximum
of 3 tools per respondent)]
11. Please list up to three examples of results achieved through using these tools, making
clear which achievements resulted from use of which tool. [text box]
12. Are you aware of any of the above tools being evaluated or assessed? [Y/N response
option, with space for additional text]
If yes, please provide details or a link to the evaluation report for each one or email it to
us ([email protected]).
13. What could be done to further supplement or improve the effectiveness of each of the
tools that you use? [text box response option]
Part 3 – Overview of current tools
14. In your opinion, are there sufficient tools and guiding documents to facilitate work to
tackle HIV-related discrimination within health care settings? [Y/N response option, with
space for additional text]
15. What gaps do you see in the materials currently available with regard to:
a. Types of health care settings? [multiple choice with text box response option]
i. General health care settings (i.e. non-specific)
ii. Hospitals
iii. Health centres/Non-hospital health facilities
iv. Community-based health services
v. Other (please specify)
b. Types/levels of health workers/staff targeted? [multiple choice with text box
response option]
i. General health workers (i.e. non-specific)
ii. Doctors and/or clinical officers
iii. Nurses, midwives and/or nurse assistants
28
iv. Community health workers
v. Health managers
vi. Other non-medical staff in health facilities (e.g. administrators,
receptionists, janitors etc.)
vii. Other (please specify)
c. Forms of discrimination covered? [text box response option]
d. Other? [text box response option]
Part 4 – Wrap-up
16. We would welcome your further thoughts on any of the relevant tools that you have used
or know about as well as any additional information you might wish to provide. [text box
response option]
Contact information for possible follow up interview (optional)
Your name _______________________________
Your organisation _______________________________
City _______________________________
Country _______________________________
E-mail address _______________________________
Telephone number _______________________________
Skype ID________________________________________
I prefer to be contacted by:
Telephone
Skype
Thank you for your participation in this survey!
29
Annex 2 – Inventory of Tools
Inventory of selected tools on HIV-related stigma and discrimination in health care settings
Introduction
This inventory was created as a part of a process of mapping tools and projects aimed at
assessing and/or addressing the negative effects of HIV-related stigma and discrimination in
health care settings. Tools selected for inclusion demonstrate the range of approaches currently
in use, but there are two important limitations to this work. Efforts have been made to create as
complete a list as possible, however it should not be considered a complete list of all potentially
relevant tools nor should it be used as a comprehensive summary of any individual tool; the
utility of this document is as a scan of available tools and approaches to provide an overview of
the current state of efforts to address HIV-related stigma and discrimination in health care
settings, and identify potential gaps. There has been no quality assessment of these tools, and as
such this inventory should not be considered as an endorsement or support for any of the
individual approaches put forth by a given tool or project.
Methodology
(1) Searches of electronic databases revealed several relevant tools and projects, followed by
targeted searches of material published by organizations working closely on HIV stigma and
discrimination. These were catalogued in a mapping matrix that formed the basis for the
categories of information included in the tables below.
(2) An online questionnaire was disseminated in Arabic, English, Russian and Spanish to
listservs, through UNAIDS regional offices, and to individuals and organizations working on
these issues. The questionnaire requested information relating to the use of existing tools, gaps in
tools, and if organizations or individuals knew of any additional tools or projects that should be
brought to the attention of the research team. Relevant responses were tracked, and any
previously unknown tools were included in the mapping review.
(3) Key informant interviews were carried out with individuals notable for their experience or
expertise working on HIV-related stigma and discrimination. In addition to determining strengths
and limitations of existing tools as well as potential gaps in currently available approaches, these
individuals were asked to provide tools that would be useful to include in the mapping.
(4) The preliminary findings of this mapping exercise were presented at an expert meeting on
HIV-related stigma and discrimination in health care settings that was hosted by UNAIDS and
the Global Health Workforce Alliance on the 10th
and 11th
November, 2015 in Geneva,
Switzerland. Meeting participants were asked to share their experiences with existing tools and
to inform the research team of any key tools they felt were missing from the analysis.
30
(5) The larger list of tools and projects was pared down to the sample below based on relevance
to the topic. Tools--rather than background documents--were chosen for inclusion, with
particular emphasis on those that focus on health care settings; in a few instances, broader tools
that nonetheless could provide relevant lessons for addressing stigma and discrimination in
health care settings were included.
Structure of the inventory
The inventory comprises a series of tables. Each table includes information on a single tool. Data
extraction across the tools was systematic in an effort to provide standardized information on
each one. To the extent possible, text was copied directly from tools into these tables; where no
succinct text was available, we paraphrased the relevant information. The categories of
information included in each table are explained below:
Name: The title of the tool.
Organization (Year): The organization(s) that produced the tool, and the year it was created.
Aim: The broader goal of the tool; how the authors describe its relevance in general.
Type of Document: The category of document e.g. trainer’s guide, fact sheet, report, etc.
Audience Intended: Who the intended implementer of the tool is, as well as which groups the
tool is designed to be used with. E.g. Intended for use by researchers to be administered to health
workers.
Populations Experiencing Stigma and/or Discrimination: Which populations are affected by
the stigma or discrimination that the tool is designed to assess or address, e.g. PLHIV, MSM,
transgender people.
Stigma and/or Discrimination: Whether the tool primarily focuses on stigma, discrimination,
or both. Where possible, we indicate whether stigma and discrimination are included separately
or dealt with together almost as though they are interchangeable.
Assess and/or Address: Whether the tool aims to assess HIV-related stigma or discrimination,
i.e. measure, study, catalogue, and analyze it; or whether it aims to address HIV-related stigma
or discrimination, i.e. limit, counter, or remove it. For example, a survey attempting to index
instances of discrimination in a health facility would be assessment, while a training tool aimed
at sensitizing health workers as to the harmful effects of discrimination would be addressing it.
Some tools further both goals.
Implementation: Details on how the tool is to be implemented or notes on how the work is to be
done.
Comments: Comments from the research team as to links with other tools, particularly
important sections in the context of this mapping, or other issues of note.
Link: A hyperlink to the tool or project.
31
Gaps appear in the tables where information could not be found within a tool on any of the above
categories. Peer-reviewed journal articles were excluded as they do not constitute ‘tools’.
The tools are organized in reverse chronological order with those published most recently
appearing first. Where one tool is meant to be used alongside another tool, these are grouped
together. Undated publications are included at the end of the inventory.
32
Inventory of Tools
2015
1.
Name: People Living with HIV Stigma Index
Organization
(Year):
ICW, GNP+ UNAIDS (2015)
Aim: The index aims to increase the evidence base and provide for advocacy by
increasing understanding of how stigma and discrimination is experienced
by people living with HIV. The evidence gained will then shape future
programmatic interventions and policy change.
Type of
Document:
An online index of standardized research projects. The People Living with
HIV Stigma Index provides a tool that measures and detects changing trends
in relation to stigma and discrimination experienced by people living with
HIV. It is based on a questionnaire that has been translated into more than
50 languages. The process of implementation is critical as it is driven by
PLHIV and their networks.
Audience
Intended:
Researchers, in consultation with the Stigma Index Partnership, to prepare a
research project of interviews and engagement with communities and
individuals living with and affected by HIV and AIDS—PLHIV are key
implementers of the interview process.
Populations
Experiencing
Stigma and/or
Discrimination:
PLHIV, including in selected cases, key populations living with HIV.
Stigma and/or
Discrimination:
Stigma focus, lists both.
Assess and/or
Address:
Both – Assesses in gathering data, but addresses by involving PLHIV in the
process and empowering individuals and communities most affected by the
epidemic.
Implementation: Different and tailored to each country, but in general, a team composed of
partners from national networks of people living with HIV, local academic
institutions and experts; technical support from the international
partnership; interviews with organizations. Interviewers are people living
with HIV, to sensitively and ethically interview other people living with
HIV and provide referrals to appropriate services.
Comments: Important work and ongoing in many different country contexts; primarily
33
stigma focused.
Link: http://stigmaindex.org/
2.
Name: Comprehensive Package for Reducing Stigma and Discrimination in Health
Facilities
Organization
(Year):
Health Policy Project--Supported by PEPFAR and USAID
(2015)
Aim: To support health facility staff in recognizing and challenging stigma and
discrimination within health facilities and creating a safe, enabling
environment for staff and patients, including people living with HIV and
other key populations, such as men who have sex with men, transgender
individuals, sex workers, and people who inject drugs.
Type of
Document:
A comprehensive package of tools, on how to assess, train, and sustain
stigma-free services. Includes a standardized questionnaire for measuring
HIV stigma and discrimination among health facility staff, a facilitator’s
training guide for a stigma-free health facility, and a resource guide for
administrators for achieving stigma-free health facilities and HIV services.
Audience
Intended:
For the overall package, health workers, health facility managers,
researchers, but primarily those working in health facilities at all levels.
Training to be conducted by facilitators—which is flexible but should
generally be with one person who is a health worker and another who is a
PLHIV or member of a key population group—who then train health
facility staff.
Populations
Experiencing
Stigma and/or
Discrimination:
People living with HIV, men who have sex with men, sex workers, people
who inject drugs, and transgender individuals.
Stigma and/or
Discrimination:
Both - but stigma is the primary focus.
Assess and/or
Address:
Both.
Implementation: Package contains flexible implementation options. See page 2 of the
training tool for more comprehensive overview. The modular approach
allows each trainer to package the training to suit his/her audience, the
workplace context, and the amount of time available. A complete course on
stigma over two to three days...A series of short two-hour sessions over
34
several weeks or months...A short intensive course of one or two days,
reinforced with one- to two-hour follow-up sessions...A stigma component
(two to three sessions) within a larger training course on HIV... The context
for this training can also vary widely. The training could take a number of
different forms...[See p.2 PDF]
Comments: Emphasis on stigma. Current and active. Also see
http://www.healthpolicyproject.com/index.cfm?id=topics-Stigma for other
links to videos, etc.
Link: http://www.healthpolicyproject.com/index.cfm?id=stigmapackage
3.
Name: Rights – Evidence – ACTion (REAct) Guide
Organization
(Year):
International HIV/AIDS Alliance
(2015)
Aim: To document human rights-related barriers in accessing HIV and health
services in order to provide adequate individual responses, and to inform
quality human rights-based HIV programming, policy and advocacy at
national, regional and global levels.
Type of
Document:
A guide that provides an introduction to Rights – Evidence – ACTion
(REAct), a community-based system for monitoring and responding to
human rights-related barriers in accessing HIV and health services.
Audience
Intended:
The guide is aimed at organizations wishing to set up and implement
REAct. REAct has been designed mainly, but not exclusively, for
community-based and civil society organizations that focus on HIV
programming and advocacy for key populations.
Populations
Experiencing
Stigma and/or
Discrimination
Key Populations, PLHIV, people who buy or sell sex, MSM, transgender
people, and people who inject drugs. This definition also includes women
and sexual minorities in contexts of acute gender inequality, and other
populations at heightened risk of human rights violations.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Both.
Implementation: Primarily done by civil society and community-based organizations,
including a possible REAct coordinating organization and multiple
35
4.
implementing organizations, and a workshop for bringing them all together
(see p. 7).
Comments: See p. 6 for note on public healthcare providers.
Link: http://www.aidsalliance.org/assets/000/001/310/REAct_User_Guide_origin
al.pdf?1424259862
Name: Webinar – A new tool to fight health insurance discrimination: Filing
complaints to state insurance commissioners
Organization
(Year):
HIV Health Reform/AIDS Foundation of Chicago; Harvard Law School
Center for Health Law and Policy Innovation
(2015)
Aim: To assist consumers, providers and advocates in filing complaints to State
Departments of Insurance to fight HIV health insurance discrimination.
Type of
Document:
Webinar on filing complaints re: HIV health insurance discrimination;
Template for Complaints.
Audience
Intended:
Consumers, care providers, advocates – the webinar walks viewers through
the process of completing template complaint letters. These letters are
designed to educate state insurance commissioners as to how health
insurance plans unfairly discriminate against people living with HIV and to
demand their offices provide oversight and require accountability.
Populations
Experiencing
Stigma and/or
Discrimination
PLHIV.
Stigma and/or
Discrimination:
Discrimination.
Assess and/or
Address:
Address.
Implementation: Individuals access webinar and create complaint letters.
Comments: US-centric, but interesting tool for filing complaints. Re-released on US
Government website (DHHS).
Link: http://www.hivhealthreform.org/2015/05/27/webinar-a-new-tool-to-fight-
health-insurance-discrimination/
https://blog.aids.gov/2015/06/new-tool-available-to-fight-insurance-
discrimination-against-persons-living-with-hiv-infection.html
36
5.
Name: Justice Programs for Public Health: A Good Practice Guide
Organization
(Year):
Open Society Foundations (2015)
Aim: To support good practices in supporting access to justice, as access to
justice is integral to improving public health and development goals.
Type of
Document:
A good practice guide based on OSF’s experience with access to justice
projects. OSF has initiated and supported community-based peer paralegals,
street-based lawyers, legal services that integrate into health care, and web-
based legal advice, and engaged in traditional community justice structures
like chiefs and elders. This guide unpacks key lessons and challenges, and
can function as a comprehensive tool for groups working with justice and
health issues.
Audience
Intended:
Justice organizations interested in addressing pressing public health needs,
and public health groups that recognize justice is as critical to public health
as medicine. It is also a resource for funders of health or justice programs.
Populations
Experiencing
Stigma and/or
Discrimination:
Sex workers, people who use drugs, PLHIV, people in need of palliative
care, Roma, people with intellectual and psychosocial disabilities.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Address.
Implementation: N/A
Comments: While the overall document addresses access to justice, a key section in the
context of addressing discrimination within health care settings is on
women living with HIV, and discrimination against Roma, among other
groups. Programs designed address limitations on access to justice for
PLHIV and can better allow people to counteract discrimination by health
care providers (p.24), among others. p. 22-27. Builds on "bringing justice
to health."
https://www.opensocietyfoundations.org/sites/default/files/bringing-justice-
health-20130923_0.pdf
Link: https://www.opensocietyfoundations.org/sites/default/files/justice-
programs-public-health-20150701_1.pdf
6.
37
Name: The Right(s) Evidence: Sex Work, Violence and HIV in Asia (A multi-
country qualitative study)
Organization
(Year):
UNDP, UNFPA, Asia Pacific Network of Sex Workers, SANGRAM, India
(2015)
Aim: The objective of the study was to better understand female, male and
transgender sex workers’ experiences of violence, the factors that increase
or decrease their vulnerability to violence and how violence relates to risk
of HIV transmission.
Type of
Document:
Report from a research partnership of UN agencies, governments, sex
worker community groups and academics. Research was carried out in
Indonesia (Jakarta), Myanmar (Yangon), Nepal (Kathmandu) and Sri Lanka
(Colombo). This regional report presents an analysis of the findings from
the four country sites.
The study comprised a total of 123 peer-to-peer in-depth qualitative
interviews with 73 female, 20 male and 30 transgender sex workers aged 18
and older. In addition, 41 key informant interviews were conducted with
police personnel, NGO officers, health and legal service providers and
national AIDS authorities for insight on contextual information to aid with
the analysis and shape the recommendations.
Audience
Intended:
Broad use: Institutions, Researchers, Governments, NGOs and Advocacy
Groups, Individuals.
Populations
Experiencing
Stigma and/or
Discrimination
Sex workers.
Stigma and/or
Discrimination:
Both--not the overt focus of the report, but definitely reported.
Assess and/or
Address:
Both – assessment component in work; current document contains
recommendations.
Implementation: N/A
Comments: In three of the four study sites, the participants reported experiencing
discrimination and violence in health care settings by doctors, nurses and
other staff, including in relation to actual or perceived HIV status. Interview
guides used in the research are not included in the report.
Link: http://www.asia-
pacific.undp.org/content/dam/rbap/docs/Research%20&%20Publications/hi
v_aids/rbap-hhd-2015-the-rights-evidence-sex-work-violence-and-hiv-in-
asia.pdf
38
7.
Name: Blueprint for the provision of comprehensive care for trans people and trans
communities in Asia and the Pacific
Organization
(Year):
United Nations Development Programme (UNDP), Asia Pacific
Transgender Network (APTN) and the United States Agency for
International Development (USAID) funded Health Policy Project (HPP)
(2015)
Aim: The purpose of the Blueprint is to strengthen and enhance the policy-
related, clinical, and public health responses for trans people in Asia and the
Pacific.
Type of
Document:
This publication outlines the priority health care needs and human rights
issues for transgender people in the Asia Pacific region. Drawing upon
inputs from trans individuals and organizations, medical professionals, and
policymakers from throughout the region, Blueprint aims to strengthen and
enhance the policy-related, clinical, and public health responses for trans
people in the region.
Audience
Intended
The primary audience for the Blueprint is health providers, policymakers
and governments. The information within the Blueprint could also serve
donors, bi- and multilateral organizations and trans and other civil society
organizations.
Populations
Experiencing
Stigma and/or
Discrimination
Transgender people.
Stigma and/or
Discrimination:
Both, but full section on discrimination and references stigma leading to
discrimination.
Assess and/or
Address:
Address.
Implementation: N/A
Comments: Section 3 of this tool contains specific discussion related to discrimination,
including the “stigma-sickness slope” in which stigma leads to
discrimination and results in worse health outcomes (p.19), and
discrimination against trans women in healthcare settings based on the fact
or perception that they are sex workers or HIV positive (p. 34).
There are two other related documents set in other regions. Neither have
been included in this review as they have less explicit focus on
discrimination in health care settings particularly in relation to HIV, but
39
they may nevertheless be useful for interested parties:
(1) Blueprint for the Provision of Comprehensive Care to Gay Men and
Other Men Who Have Sex with Men (MSM) in Latin America and the
Caribbean:
http://www.paho.org/hq/dmdocuments/2010/Blueprint%20MSM%20Final
%20ENGLISH.pdf
(2) Blueprint for the Provision of Comprehensive Care for Trans Persons
and their Communities in the Caribbean and Other Anglophone Countries
http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&
gid=28440&lang=en
Link: http://www.asia-
pacific.undp.org/content/rbap/en/home/library/democratic_governance/hiv_
aids/blueprint-for-the-provision-of-comprehensive-care-for-trans-peop.html
8.
Name: Positive Protection! Empowering Women Affected by HIV to Protect their
Rights at Health Care Settings
Organization
(Year):
UNDP
(Forthcoming)
Aim: To empower women affected by HIV in Nepal with the information,
attitudes and skills they need to ensure that their rights are respected when
they seek sexual and reproductive health care services and to seek justice if
they are violated.
Type of
Document:
Toolkit and training, divided into three modules: (1) “Know Your
Epidemic! Know Your Rights!” provides an overview of the HIV epidemic
in Nepal and introduces the sexual and reproductive health rights of women
affected by HIV at health care settings. (2) “Seeking Justice” provides
information on how women affected by HIV can seek justice if their rights
are violated. “Community Mobilisation: Doing It for Ourselves!” leads
participants through a community mobilization process which culminates in
the development of an action plan to address problems that lead to the
violation of the rights of women affected by HIV in sexual and reproductive
health care settings.
Audience
Intended
Networks, community-based organizations, non-governmental
organizations and international agencies working with women affected by
HIV to provide training to women affected by HIV.
Populations
Experiencing
Women and girls living with HIV; Female sex workers; Female drug users;
Transgender women; Women in sero-discordant relationships; Female
40
Stigma and/or
Discrimination:
partners of men with high-risk behaviours (for example, who are clients of
sex workers, use drugs, have sex with men, are migrants).
Stigma and/or
Discrimination:
Both, and generally connected.
Assess and/or
Address:
Address.
Implementation: If delivered as one workshop, it will take four days. It can be delivered as
three consecutive modules in separate workshops.
Comments: Nepal focus. Participant’s book includes background on relevant national
law, and worksheets forms that function as tools.
Link: http://www.np.undp.org/content/nepal/en/home/projects/_jcr_content/center
parsys/download/file.res/Facilitator's%20Guide%20(English).pdf
2014
9.
Name: Addressing Stigma: A blueprint for improving HIV/STD prevention and
care outcomes for black and latino gay men
Organization
(Year):
National Alliance of State and Territorial AIDS Directors (NASTAD)
(2014)
Aim: To reduce stigma in public health practice and promote access to HIV and
STD prevention and treatment among gay men/MSM.
Type of
Document:
Blueprint with background on addressing stigma, recommended steps for
removing stigma from public health practice, linkages to care and retention
in care, and treatment adherence. Contains background and analysis drawn
from a stigma survey, a stigma toolkit, and optimal care checklists.
Audience
Intended
Directors of HIV prevention programs implemented by health departments
and community partners.
Populations
Experiencing
Stigma and/or
Discrimination:
Black and Latino gay men, and other MSM.
Stigma and/or
Discrimination:
Stigma.
Assess and/or
Address:
Address.
Implementation: N/A
Comments: US focus. Some recommended steps have guidance for healthcare
41
providers.
Link: https://www.nastad.org/sites/default/files/NASTAD-NCSD-Report-
Addressing-Stigma-May-2014.pdf
10.
Name: Reduction of HIV-related stigma and discrimination [Guidance note]
Organization
(Year):
UNAIDS (2014)
Aim: To assist countries in addressing aspects of HIV-related stigma and
discrimination in national AIDS responses through political initiatives,
empowering people living with HIV and other key populations to challenge
stigma and discrimination, and, most importantly, costing, budgeting,
implementing, monitoring and evaluating sufficient programmes aimed at
eliminating stigma and discrimination within national AIDS responses,
including through the concept note development processes for submission
to the Global Fund.
Type of
Document:
Guidance Note containing background; key elements for national AIDS
responses and programming; information on focus populations; data
requirements; implementation challenges; main activities; key indicators;
approaches to costing; and information on addressing gender, human rights
and equity issues.
Audience
Intended:
Policy makers and programme managers attempting to address stigma and
discrimination in national AIDS responses.
Populations
Experiencing
Stigma and/or
Discrimination:
PLHIV and other key populations (in most settings, men who have sex with
men, transgender people, people who inject drugs and sex workers, but not
limited).
Stigma and/or
Discrimination:
Both - most often combined (stigma and discrimination) but, each given
separate discussion, particularly in structural section.
Assess and/or
Address:
Address.
Implementation: Guidance note--part of resource kit for high impact programming, and
designed to assist countries. Provides some context and questions that
should be considered at several levels, and critically, some concise
guidelines related to implementation of programming itself. In this sense,
may be used to improve programming and tools.
Comments: Part of "resource kit for high-impact programming".
42
Link: http://www.unaids.org/sites/default/files/media_asset/2014unaidsguidancen
ote_stigma_en.pdf
11.
Name: Practical Manual: Legal Environment Assessment for HIV, An operational
guide to conducting national legal, regulatory and policy assessments for
HIV
Organization
(Year):
UNDP (2014)
Aim: To assist governments, civil society and other key stakeholders to develop
evidence-informed policy and strategy, to review and reform laws and
policies based on human rights considerations and support increased
capacity to achieve enabling legal environments for effective HIV
responses.
Type of
Document:
A manual with step-by-step guidance on how to undertake a national Legal
Environment Assessment (LEA) with concrete case studies, tools and
resources. As a follow up to the Global Commission on HIV and the Law,
the LEA offers an opportunity to look at priority HIV, legal and human
rights issues identified by the Global Commission. This includes a specific
focus on reviewing the legal and regulatory framework in the HIV context
with respect to stigma and discrimination; women and gender; children and
young people; criminal laws and key populations; and intellectual property
law and access to HIV treatment. The manual has five sections for a
national LEA: (1) Planning (2) Assessment (3) Feedback and finalization
(4) Dissemination, implementation and impact (5) Documenting the
process: communication, monitoring and evaluation, and coordination.
Audience
Intended:
Countries undertaking LEAs.
Populations
Experiencing
Stigma and/or
Discrimination:
PLHIV, women and girls, children and young people, criminalized
populations and other key populations.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Assess.
Implementation: The manual can be used in all countries, regardless of the type of LEA that
43
is being conducted and the scope or the stage of development and
implementation of HIV-related laws, regulations and policies. It
is recommended to use the manual as a reference guide when developing
and planning LEAs. The suggestions regarding possible processes and
structures may guide decision-making regarding a country’s LEA—process
to follow, who will be involved and how the assessment will take place—
based on its particular needs, resources and time constraints.
Comments: LEAs conducted in several countries for numerous projects. Goes far
beyond stigma and discrimination in health care settings but should include
this. For example, laws, regulations and policies examined by LEAs include
those regulating the HIV response, often related to or encompassed within
those regulating the provision of health care. Key actionable
recommendations from LEAs may include improving the legal environment
in the interest of discrimination-free health care.
Link: http://www.undp.org/content/undp/en/home/librarypage/hiv-aids/practical-
manual--legal-environment-assessment-for-hiv--an-opera.html
12
Name: Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and
Care for Key Populations
Organization
(Year):
WHO (2014)
Aim: These guidelines aim to: provide a comprehensive package of evidence-
based HIV-related recommendations for all key populations; increase
awareness of the needs of and issues important to key populations; improve
access, coverage and uptake of effective and acceptable services; and
catalyze greater national and global commitment to adequate funding and
services. The guidelines explicitly address “critical enablers,” including
laws and policies, addressing stigma and discrimination, community
empowerment, and addressing violence.
Type of
Document:
Consolidated guidelines document on HIV prevention, diagnosis, care, and
treatment for five key populations. Provides normative guidance and a
package of interventions.
Audience
Intended:
Individuals and organizations engaged in health programming for key
populations.
Populations
Experiencing
Stigma and/or
Five key populations: MSM, people who inject drugs, people in prisons and
other closed settings, sex workers, transgender people (and also vulnerable
populations, e.g. adolescents in certain situations or contexts).
44
Discrimination:
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Address.
Implementation: Functions as in-depth recommendations and guidance keyed to key
populations, so not a "tool" in the sense that several others are, but the
package of interventions would be used in design and implementation
stages particularly for policy.
Comments: This document goes beyond stigma and discrimination in health care
settings but includes attention to these issues.
See section 5.2 (p.96) including bit on training and sensitizing health
workers. Also see supplement:
http://apps.who.int/iris/bitstream/10665/177992/1/9789241508995_eng.pdf
?ua=1 (Background generally)
Link: http://apps.who.int/iris/bitstream/10665/128048/1/9789241507431_eng.pdf
?ua=1&ua=1
13.
Name: Tool to set and monitor targets for HIV prevention, diagnosis, treatment and
care for key populations
(Supplement to the 2014 “Consolidated guidelines for HIV prevention,
diagnosis, treatment and care for key populations” above)
Organization
(Year):
WHO (2015)
Aim: To provide guidance on monitoring and evaluating the implementation of
the comprehensive package of interventions to address HIV among key
populations.
Type of
Document:
This document provides countries with: (1) a set of harmonized indicators
to examine the implementation of the package of interventions to address
HIV among key populations; and (2) guidance on setting targets for these
indicators. The framework presented here is designed to help plan and
assess progress at the macro level, in particular for national and subnational
programming.
Audience
Intended:
Countries planning and monitoring efforts to address HIV among key
populations. This planning and assessment process should involve
government agencies, nongovernmental organizations (NGOs),
communities and service providers involved in developing, implementing,
45
monitoring and evaluating HIV prevention, treatment and care programs for
these key populations.
Populations
Experiencing
Stigma and/or
Discrimination:
Men who have sex with men, people in prisons and other closed settings,
people who inject drugs, sex workers and transgender people.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Address.
Implementation: The framework presented here is designed to help plan and assess progress
at the macro level, in particular for national and subnational programming.
It goes beyond stigma and discrimination in health care settings but includes
attention to these issues. The PLHIV Stigma Index is proposed as a way of
assessing PLHIVs’ experiences of stigma and discrimination as well as
health providers’ attitudes. Attention is also given to the diversity of key
populations and the need to ensure appropriate disaggregation of data e.g.
by age, gender, geographic location and other ‘risk characteristics’.
Comments: This document should be read in conjunction with the “consolidated
guidelines” above.
Link: http://www.who.int/hiv/pub/toolkits/kpp-monitoring-tools/en/
14.
Name: Tools for Integrating Rights and Health into Educational Clinical Practice
Organization
(Year):
The International Federation of Gynecology and Obstetrics (FIGO)
(2014)
Aim: For students and teachers to gain insight into the personal actions and
healthcare infrastructures that can best support fundamental human rights in
health care and especially in reproductive healthcare.
Type of
Document:
Checklist for quality care that allows the user to consider how rights are
protected or infringed by providers and the healthcare system, and case
studies to explore how healthcare outcomes and human rights are
interdependent.
Audience
Intended:
For the checklist, teachers and students, as well as general consumers of
health care. For the case studies: facilitator guides are provided for teachers.
They include suggested discussion topics and resources for learning more
about the clinical and rights aspects of each case. Teachers may choose to
provide students with the reference list to help them analyze the case as a
46
homework assignment or as follow-up to more in-depth study after the
initial discussion. The studies themselves may be used by students and
teachers alike.
Populations
Experiencing
Stigma and/or
Discrimination:
Women accessing health services.
Stigma and/or
Discrimination:
Discrimination.
Assess and/or
Address:
Both.
Implementation: For flexible use, primarily by teachers and students.
Comments: See in particular case study 7 regarding an unwelcoming birth facility.
Link: https://www.glowm.com/tools_integrating_health
15.
Name: HealthWISE - Work Improvement in Health Services
Organization
(Year):
International Labour Organisation
(2014)
Aim To promote decent work in the health sector, which must include workers’
health and well-being, since the quality of the work environment can
influence the quality of care provided by health workers.
Type of
Document:
HealthWISE -- a joint ILO/WHO publication -- is a practical, participatory
quality improvement tool for health facilities. The topics are organized in
eight modules addressing occupational safety and health, personnel
management and environmental health issues.
Audience
Intended:
HealthWISE is designed for use by all who are concerned with improving
workplaces in the health sector, including health workers and health-care
managers, supervisors, workers’ and employers’ representatives, labor
inspectors, occupational health specialists, trainers and educators.
It encourages managers and staff to work together to improve workplaces
and practices. HealthWISE promotes the application of smart, simple and
low-cost solutions leading to tangible benefits for workers and health
services, and ultimately for patients.
Populations
Experiencing
Stigma and/or
Health workers, including workers with HIV.
47
Discrimination
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Address.
Implementation: HealthWISE combines action and learning. The Action Manual helps
initiate and sustain changes for improvement, using a checklist as a
workplace assessment tool, designed for identifying and prioritizing areas
of action. Each of the eight modules illustrates key checkpoints to help
guide action. Module 4 is explicitly geared at tackling discrimination,
harassment and violence at the workplace, as these affect health workforce.
The accompanying Trainers’ Guide contains guidance and tools for a
training course.
Comments: See Module 4 and the discussion of discrimination experienced by health
workers, p. 3 of trainers’ guide.
Link: Both documents are available at:
http://www.ilo.org/sector/Resources/training-
materials/WCMS_250540/lang--en/index.htm
16.
Name: Promoting the Human Rights of LGBT People in the World of Work:
Building equal opportunities in the world of work: combating LGBT-
phobia. (in Portuguese)
Organization
(Year):
ILO, UNAIDS, UNDP
(2014)
Aim To build the capacity of people in the workplace to create a working
environment that is inclusive and respectful of HIV status and sexual
diversity.
Type of
Document:
Four case studies with discussion questions are presented. Each one focuses
on an example of discrimination in the workplace based on sexual
orientation, gender identity or HIV status. It is “an invitation to reflect and
to act”.
Audience
Intended:
LGBT populations, people living with HIV, workplace mangers and other
workers; people working in human resources or the promotion of diversity
in the work place, trade unions.
Populations
Experiencing
Stigma and/or
LGBT populations
48
Discrimination
Stigma and/or
Discrimination:
Discrimination, with some mention of stigma. Includes attention to human
rights relevant to work and non-discrimination.
Assess and/or
Address:
Address
Implementation: This document can be used internally by organizations to have discussions
among different groups of workers to ensure an inclusive and respectful
working environment. Trade unions may also want to incorporate the
materials into any relevant training to promote these good practices across
different organizations and industries. If there are open LGBT people within
a workplace they should be central to deciding how the materials might best
be used and they should be involved in any implementation activities.
Comments: Brazil focus; in Portuguese. Not directly relevant to health care settings but
an interesting model for considering discrimination within the workplace
from which useful lessons might be drawn.
Link: Only soft copy available
2013
17.
Name: Capacity Development Toolkit for HIV/AIDS, TB and Malaria Responses
Organization
(Year):
UNDP Global Fund Programme
Range of documents: 2005-2013
Aim The toolkit provides practical guidance on how to strengthen institutional
capacities for implementing national disease responses for HIV and AIDS,
Tuberculosis and Malaria.
Type of
Document:
Online resource list of tools and documents--some links broken, but
framework clear with four inter-linked sections: (1) Enablers is focused on
the policy and legal environment for implementing disease responses; (2)
Governance deals with program management, accountability and
oversight; (3) Implementation looks at the specific management capacities;
and (4) Process looks at how to facilitate a capacity development
assessment, planning and implementation process. Each section contains
guidance, tools and templates to support capacity development for better
health outcomes.
Audience
Intended:
Those engaged in national disease response programming -- see
programming under enablers for Stigma and Discrimination section, as
several approaches are discussed.
49
Populations
Experiencing
Stigma and/or
Discrimination
People living with HIV, also TB and Malaria.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Both (technically lists tools that do both and are listed separately in the
document, but much more focused on addressing).
Implementation: Multiple tools, but implementation tab shows institutional arrangements.
Comments: This is a list of different tools, each for a different purpose; further details
can be gleaned from reviewing each tool.
Link: http://www.undp-globalfund-capacitydevelopment.org/home/cd-toolkit-for-
hivaids,-tb-malaria-responses/enablers/4-programming/reducing-stigma-
and-discrimination.aspx
18.
Name: “The Time Has Come” Enhancing HIV, STI and other sexual health
services for MSM and transgender people in Asia and the Pacific: Training
package for health providers to reduce stigma in health care settings
Organization
(Year):
UNDP, WHO
(2013)
Aim: To impart practical, sustainable knowledge and skills to program managers,
frontline service managers and health policy professionals that can enhance
their leadership capacity and improve programming and service delivery.
Type of
Document:
A 5-day training toolkit built around the following modules: (1) Context
building, (2) MSM and transgender programming, (3) enabling
environments, (4) strategic information, (5) program management.
Audience
Intended:
It is designed to be particularly relevant for health care workers, as well as
selected staff from funders, national and provincial HIV programs, Global
Fund project managers, policy-makers, frontline managers and advocates.
Training is to be delivered by expert facilitators to program managers,
frontline service managers and health policy professionals.
Population
Experiencing
Stigma and/or
Discrimination:
MSM and transgender people.
Stigma and/or Stigma mainly, some focus on discrimination.
50
Discrimination:
Assess and/or
Address:
Address.
Implementation: 5-day training. A "dynamic, interactive training program designed and
delivered by expert peer trainers." "Additionally, it is recommended not to
overly adapt the training modules. In some of the pilot trainings, the
package was substantially changed to the extent that all five modules were
attempted in a two-day period, and followed by a half-day ‘stakeholder
meeting’ with senior government and other personnel. This was in an
attempt to advocate for the future use of the package. While such advocacy
is essential for the success of any local sustainability, it is recommended
that any local stakeholders’ advocacy meetings be planned as an additional
activity, not to be included into the training agenda..." (See p. 17 for more
cautions re: adaptation and translation of the package.)
Comments: Comprehensive tool; focus on stigma reduction. Section on enabling
environments, including attention to laws and policies, is most relevant to
discrimination.
Link: http://www.thetimehascome.info/file/rbap-hhd-2013-the-time-has-come.pdf
19.
Name: Measuring HIV Stigma and Discrimination Among Health Facility Staff
Organization
(Year):
Health Policy Project/USAID (2013)
Aim: To facilitate routine monitoring of HIV-related stigma, as well as the
expansion and improvement of programming and policies at the health-
facility level.
Type of
Document:
Globally standardized questionnaire (2 versions) for measuring stigma and
discrimination in health care facilities. Two questionnaires are publicly
available: a comprehensive brief version for program planning, evaluation,
and research purposes, and a monitoring questionnaire that includes only the
eight questions needed to collect six globally approved indicators for
measuring stigma and discrimination in health facilities.
Stigma and/or
Discrimination:
Both.
Audience
intended:
Researchers, and health facility staff. Testing involved administration to
clinical and nonclinical staff members, with a mix of self- and interviewer-
administered modes.
51
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Implementation: Questionnaires for administration to health facility workers that can be
either self- or interviewer-administered.
Assess and/or
Address:
Assess.
Comments: Now included in the Health Policy Project ‘Comprehensive package’ of
tools listed above.
Link: http://www.healthpolicyproject.com/index.cfm?ID=publications&get=pubI
D&pubID=49
20.
Name: Protecting the rights of key HIV affected women and girls in healthcare
settings: a legal scan (regional report, Bangladesh, India, Pakistan, Nepal)
Organization
(Year):
Women of Asia Pacific Plus, APN Plus Positive Change, South Asian
Association for Regional Cooperation in Law (SAARCLAW), UNDP
(2013)
Aim: To identify existing protective laws (including constitutional provisions)
and legal mechanisms for seeking protection or redress for violations of
rights of key HIV affected women and girls (KAWG) in health care
settings; To document rights violations experienced by KAWG in health
care settings; To document selected court rulings on violations of rights of
KAWG in health care settings; To document cases where KAWG have been
able to access justice for violations of rights in health care settings through
legal mechanisms; To identify gaps in laws and legal mechanisms that
protect KAWG from such violations; To develop recommendations for
governments, the legal sector, health care institutions, and SAARCLAW for
actions to be taken to improve the legal environment in order to protect the
rights of KAWG in health care settings.
Type of
Document:
Regional report focused on legal frameworks, discrimination, violence and
rights abuses faced by women and girls in healthcare settings.
Audience
Intended:
SAARCLAW chapters and other institutions, researchers, governments
advocacy groups.
Population
Experiencing
Stigma and/or
Women and girls affected by HIV.
52
Discrimination:
Stigma and/or
Discrimination:
Both--greater focus on discrimination.
Assess and/or
Address:
Both (assessment of legal environment but also recommendations).
Implementation: N/A
Comments: Discrete focus on discrimination and other legally actionable issues (e.g.
many forms of violence).
Link: http://www.undp.org/content/dam/rbap/docs/Research%20&%20Publicatio
ns/hiv_aids/rbap-hhd-2013-protecting-rights-of-key-hiv-affected-wg-health-
care-settings.pdf
2012
21.
Name: Lost in Transition: Transgender People, Rights and HIV Vulnerability in the
Asia-Pacific Region
Organization
(Year):
Asia Pacific Transgender Network, UNDP
(2012)
Aim: To examine literature on existing laws, regulations, policies and practices
that prompt, reinforce, reflect or express stigma and prejudice towards
transgender people; to identify vulnerabilities to HIV and barriers to access
or uptake of HIV-related healthcare services; and to establish a research
agenda aimed at providing the sort of data that will enable a reduction in
future risk, as well as better access to treatment, care and support for
transgender persons living with HIV.
Type of
Document:
A review of existing literature on transgender people's human rights and
HIV vulnerability across the Asia-Pacific region.
Audience
Intended:
Researchers and others interested in rights and vulnerabilities of transgender
people in the Asia-Pacific region.
Population
Experiencing
Stigma and/or
Discrimination:
Transgender people.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Assess.
53
Implementation: N/A
Comments: See p. 15 for discrimination discussion, p. 33 for healthcare discussion, p.
13 stigma-sickness slope is useful conceptually.
Link: http://www.undp.org/content/dam/undp/library/hivaids/UNDP_HIV_Transg
ender_report_Lost_in_Transition_May_2012.pdf
22.
Name: Measuring HIV stigma and discrimination
Organization
(Year):
STRIVE, UKaid, London School of Hygiene and Tropical Medicine, ICRW
(2012)
Aim: This brief is designed to guide researchers in the study of HIV-related
stigma and discrimination, either as the main focus of research or as a
complement to related topics.
Type of
Document:
Technical brief to guide researchers in the study of HIV-related
stigma and discrimination, including specific questions for measuring
the key conceptual domains of stigma and discrimination across
three populations: people living with HIV, the general population
and healthcare workers.
Audience
Intended:
Researchers. Conceptual domains cover multiple areas of inquiry, and
illustrative questions aimed at general population, healthcare workers, and
PLHIV, but document is to be used to guide further research efforts.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Both--mostly 'stigma and discrimination,' more on stigma, but interesting
breakdown of experienced stigma (outside legal purview) and
discrimination (inside legal purview) in illustrative questions (p.3).
Assess and/or
Address:
Assess.
Implementation: This is guidance for researchers. Offers several illustrative examples of
questions to ask, and highlights areas where additional research is needed.
Comments: Brief user-friendly tool.
Link: http://strive.lshtm.ac.uk/system/files/attachments/STRIVE_stigma%20brief-
A4.pdf
23.
Name: Key Programmes to Reduce Stigma and Discrimination and Increase
54
Access to Justice in National HIV Responses (Guidance Note)
Organization
(Year):
UNAIDS (2012)
Aim: To help governments eliminate stigma, discrimination, and punitive
approaches related to HIV in national responses.
Type of
Document:
Guidance and tools (presented as a number of programs, fact sheet style)
aimed at reduction of stigma and discrimination and increasing access to
justice in national HIV responses. Tools include a manual on the program
definitions and a tool to estimate the cost of launching and developing HIV-
related human rights programs.
Audience
Intended:
Countries/policymakers—series of key programs that UNAIDS
recommends including in National Strategic Plans for HIV and
incorporation as essential activities in operational plans.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV, those vulnerable to HIV, and other key populations.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Address.
Implementation: The coverage and scale of these programs should be tailored to national and
local epidemics, expanded to the point where they can make a difference,
and evaluated for further learning.
Comments: Part 6 is the most on point: "Training for health care providers on human
rights and medical ethics related to HIV".
Link: http://www.unaids.org/sites/default/files/media_asset/Key_Human_Rights_
Programmes_en_May2012_0.pdf
Human Rights Costing Tool User Guide at:
http://www.unaids.org/sites/default/files/sub_landing/files/The_HRCT_Use
r_Guide_FINAL_2012-07-09.pdf
Human Rights Costing Tool at:
http://www.unaids.org/en/media/unaids/contentassets/documents/data-and-
analysis/tools/The_Human_Rights_Costing_Tool_v_1_5_May-2012.xlsm
24.
Name: Human Rights of People Living with HIV or AIDS (in Spanish)
55
Organization
(Year):
Comisión Nacional de los Derechos Humanos, Mexico
(2012)
Aim: To increase understanding of the rights of PLHIV, and provide information
and resources for PLHIV and advocates.
Type of
Document:
An overview of human rights concerns—particularly centered around
discrimination—experienced by PLHIV. Includes a primer that sets out the
rights of PLHIV, and instructions as to where one can file a complaint if he
or she has experienced discrimination.
Audience
Intended:
PLHIV and others interested in the rights of people living with HIV or
AIDS, those wishing to know how to file a discrimination complaint.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV, MSM, Sex Workers, Drug Users, Women and Children.
Stigma and/or
Discrimination:
Discrimination primarily, with a few references to stigma.
Assess and/or
Address:
Address.
Implementation: N/A
Comments: Mexico focus. Includes rights to health services and information from
public health institutions, and the right to know the procedures for filing
complaints related to abuse of rights in health institutions, p. 13-14.
Link: http://www.cndh.org.mx/sites/all/doc/cartillas/1_Cartilla_VIH_sida.pdf
2011
25.
Name: Sexual Minorities, Human Rights, and HIV/AIDS: A Trainer's Guide
Organization
(Year):
Botswana Network on Ethics, Law, and HIV/AIDS
(2011)
Aim: To raise awareness and challenge stigma and discrimination towards sexual
minorities.
Type of
Document:
Facilitator’s guide for a set of educational and training exercises based on a
participatory approach, including discussion, small group activities, case
studies and other methods.
Audience
Intended:
Organizations and individuals engaged in training, service providers, global
health workers. It is designed for the use of the Prevention and Research
Initiative for Sexual Minorities (PRISM) and other organizations involved
56
in training on these issues. It will be used by trainers to conduct short
workshops to teach people about the issues facing sexual minorities.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV, "sexual minorities".
Stigma and/or
Discrimination:
Both - Stigma focus.
Assess and/or
Address:
Address.
Implementation: For use by trainers to conduct short workshops. "Participatory approach…to
make learning lively and fun…fosters a sense of initiative and
responsibility." The document is written for a facilitator. Session plans are
included, and optional exercises can be selected to make a custom training
plan. It is designed to be used in a flexible way for different target groups or
learning situations. 3-5 day workshop, or short sessions over several weeks,
or just a few exercises. Emphasizes participatory learning and moving from
awareness to action.
Comments: Botswana focus. The document outlines a full workshop. In particular See
A14-stigma and discrimination by service providers.
Link: http://www.bonela.org/images/doc/bonela_prism_training_manual_2011.pd
f
26.
Name: Men who have Sex with Men: An Introductory Guide for Health Care
Workers in Africa
Organization
(Year):
Desmond Tutu HIV Foundation
(2011)
Aim: This manual and training program aims to educate health care workers with
the necessary skills and knowledge to provide the sensitive services that
support and adequately cater for MSM and their unique needs within
African health care settings.
Type of
Document:
Guide to help counselor or health care provider address the specific
healthcare needs of MSM, the risks of HIV infection or the anal
acquisition of sexually transmitted infections (STIs) in sub-Saharan Africa.
Includes a pre-course questionnaire, post course assessment, and a series of
exercises to build knowledge and understanding.
Audience This program is aimed at HIV counselors and other health care workers
57
Intended: who operate in Africa and have varying degrees of experience with MSM. It
has been designed specifically for individuals who already have a basic
understanding of and experience in the HIV sector.
Population
Experiencing
Stigma and/or
Discrimination:
MSM living with or vulnerable to HIV.
Stigma and/or
Discrimination:
Both - and distinction explained.
Assess and/or
Address:
Both.
Implementation: Group study/facilitator: It is suggested that a facilitator experienced in
counseling or working with MSM lead all trainings but where this is not
possible an experienced HIV counselor or health care worker would be able
to facilitate the program. Case studies and interactive exercises are provided
in order to practice the study material within a group but this manual can
also be used by individuals who are not able to attend group sessions.
Comments: Explicitly aimed at health care providers and includes an evaluative
component and assessment.
Link: http://www.desmondtutuhivfoundation.org.za/documents/MSM-Manual.pdf
27.
Name: Integrating Stigma Reduction Into HIV Programming: Lessons from the
Africa Regional Stigma Training Programme
Organization
(Year):
International HIV/AIDS Alliance; SIDA and Norad
(2011)
Aim: The aim of this tool is to present different examples of stigma reduction
activities that have been integrated into HIV programs for long-term impact
and sustainability. These examples have been taken from organizations and
programs around Africa.
Type of
Document:
This document illustrates lessons learned from implementing the toolkit
Understanding and Challenging HIV Stigma across Africa (See Tool 58 in
this inventory for the tool itself.) Understanding and Challenging HIV
Stigma was written for and by HIV trainers in Africa.
Audience
Intended:
The toolkit has been designed to help trainers plan and organize educational
sessions with community leaders, or organize groups to raise awareness and
58
promote practical action to challenge HIV stigma and discrimination. It may
be useful to those designing stigma reduction programs, usually in training
courses or workplace and community activities. It could also be useful for
policymakers and state program planners.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Heavily stigma, often connected, a few separate references to
discrimination.
Assess and/or
Address:
Address.
Implementation: The range of examples shared here illustrate how stigma interventions can
be tailored to fit many contexts.
Comments: Useful stigma reduction methodology.
Link: http://www.iasociety.org/web/webcontent/file/integratingstigmareductionint
ohivprogramming_lessonsafrica_alliance.pdf
28.
Name: The Socio-Economic Impact of HIV at the Household Level in Asia: A
Regional Analysis
Organization
(Year):
UNDP
(2011)
Aim: This analysis is based on the data and findings from the country level
studies and is meant to support the development of targeted, evidence-
informed impact mitigation policies and programs in the region, with
particular emphasis on HIV-sensitive social protection.
Type of
Document:
UNDP-led nationwide socioeconomic impact studies in Cambodia, China,
India, Indonesia, and Viet Nam between 2005 and 2010.
Audience
Intended:
National and provincial governments, as well as other HIV-stakeholders
trying to strengthen efforts towards impact mitigation and HIV-sensitive
social protection in the region
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV and households affected by HIV.
Stigma and/or
Discrimination:
Both, primarily stigma and discrimination but some separate treatment.
59
Assess and/or
Address:
Both (surveys and project assess; analysis and recommendations address)
Implementation: N/A
Comments: The data and discussion are relevant to stigma and discrimination: the
analysis documents discrimination in health facilities and some of the real
and potential impacts of this on PLHIV. See p. 55 for discrimination in
health facilities in Indonesia.
Link: http://www.undp.org/content/dam/undp/library/hivaids/SEImpactOfHIVAt
TheHouseholdLevelInAsia-RegionalAnalysis.pdf
29.
Name: The Socio-Economic Impact of HIV at the Household Level in Asia: A
Regional Analysis of the Impact on Women and Girls
Organization
(Year):
UNDP
(2011)
Aim: To measure the specific impact of HIV on women and girls to support the
use of this information for evidence-based policy interventions.
Type of
Document:
Using the same data as the preceding tool (regional analysis), analyses
focus on comparisons between HIV-affected and non-affected households
for impacts on women and girls regarding key socioeconomic issues:
income, employment, revenues, expenditures, coping mechanisms, health,
education, food security, family composition, pregnancy and stigma and
discrimination.
Audience
Intended:
National and provincial governments, as well as other HIV-stakeholders
trying to strengthen efforts towards impact mitigation and HIV-sensitive
social protection in the region.
Population
Experiencing
Stigma and/or
Discrimination:
Women and Girls impacted by HIV.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Both (surveys and project assess; analysis and recommendations address).
Implementation: N/A
Comments: See p. 26 for figure of PLHIV experiencing discrimination in health
facilities (graph).
Link: http://www.undp.org/content/dam/undp/library/hivaids/SEImpactOfHIVAt
60
TheHouseholdLevelInAsia-WomenAndGirls.pdf
2010
30.
Name: Understanding Drug Related Stigma: Tools for Better Practice and Social
Change. Facilitators’ Guide.
Organization
(Year):
Harm Reduction Coalition
(2010)
Aim: To give participants a distinct set of knowledge and skills to help them
understand and address drug-related stigma.
Type of
Document:
Curriculum outline for trainers.
Audience
Intended:
This training is relevant for community-based direct service staff,
caseworkers, therapists, peer advocates, program administrators, medical
providers, and all who are interested in understanding and addressing drug
related stigma.
Population
Experiencing
Stigma and/or
Discrimination:
Drug users.
Stigma and/or
Discrimination:
Both - and distinction explained.
Assess and/or
Address:
Address.
Implementation: Half-day (3 hour) training.
Comments:
Link: http://harmreduction.org/wp-content/uploads/2012/02/stigma-
facilitators.pdf
31.
Name: Understanding and Challenging Stigma towards Men who have Sex with
Men: Toolkit for Action (Cambodia)
Organization
(Year):
ICRW and Pact International; USAID
2010
Aim: To support progress by Government, NGOs and CBOs by: raising the
understanding of service providers and the community on MSM, gender
issues underlying MSM, and how stigma and lack of human rights fuels
61
HIV transmission. Building public awareness and support to stop stigma
and discrimination toward MSM. Fostering support for health workers and
other service providers to develop new codes of practice for how they
counsel, test and treat MSM patients.
Type of
Document:
Toolkit for working against stigma and discrimination towards MSM,
adapted for use in Cambodia.
Audience
Intended:
Facilitators of training, organizations working in this sphere, with the aim of
helping (among others) health workers, police officers, and community
members become more aware of stigma and discrimination toward MSM
and what can be done to change it.
Population
Experiencing
Stigma and/or
Discrimination:
MSM.
Stigma and/or
Discrimination:
Both – and distinction explained.
Assess and/or
Address:
Address.
Implementation: This toolkit uses a participatory approach based on discussion, small group
activities, pictures, stories, and other methods. It includes a flexible
collection of optional exercises. Exercises can be used with a single target
group (e.g., health workers or MSM); or with a mixed target group (e.g.,
combining health workers, MSM, and community members together). They
can be combined into a three to five day workshop, or a single community
meeting, or short sessions given once a week over several weeks (e.g. to a
MSM support group or the staff of a health facility), or two to three
exercises introduced as part of a longer and broader training program on
HIV and AIDS.
Comments: Adapted for use in multiple countries; see other listings.
Link: http://www.icrw.org/files/publications/Understanding-and-Challenging-
Stigma-toward-Men-who-have-Sex-with-Men-Toolkit-for-Action.pdf
32.
Name: Understanding and Challenging Stigma towards Sex Workers and HIV in
Vietnam: Toolkit for Action
Organization
(Year):
Institute for Social Development Studies and ICRW
2010
Aim: To improve service providers’ and the community’s understanding of sex
62
workers and how stigma and lack of human rights fuels HIV transmission.
To build public recognition of the problem of stigma and discrimination
toward sex workers and public support and commitment to stop stigma and
discrimination. To get health workers and other service providers to start
developing new codes of practice for how they counsel, test, and treat sex
worker patients. A key aim of the toolkit is to help sex workers break out of
a life on the margins, build improved relations with their families and
communities, reassert their rights, protect themselves from HIV and other
STIs, and get better access to health services.
Type of
Document:
The toolkit is a collection of educational exercises to help explore,
understand, and challenge stigma and discrimination toward sex workers.
Audience
Intended:
For facilitators of training, particularly individuals and organizations that
are working to stop stigma and discrimination toward sex workers. One
goal of the toolkit is to help health care workers, police officers, and
community members become more aware of stigma and discrimination
toward sex workers and what can be done to change it.
Population
Experiencing
Stigma and/or
Discrimination:
Sex workers.
Stigma and/or
Discrimination:
Both – and distinction explained, but more on stigma and usually combined.
Assess and/or
Address:
Address.
Implementation: See General “Understanding and Challenging” document for more on
implementation of each of these components.
Comments: Part of the "Understanding and Challenging" series, see other entries.
Link: http://www.isds.org.vn/download/tailieu/xuatbanpham/swtoolkit/Toolkit%2
0for%20action%20-
%20Reducing%20stigma%20toward%20sex%20workers%20and%20HIV
%20in%20Vietnam.PDF
33.
Name: Understanding and Challenging Stigma towards Injecting Drug Users and
HIV in Vietnam: Toolkit for Action
Organization
(Year):
Institute for Social Development Studies and ICRW; USAID
2010
Aim: a) Educate service providers, law enforcement agents, rehabilitation center
63
officials, and the community about addiction, the lives of injecting drug
users and how stigma and lack of human rights fuels HIV transmission.
b) Build public awareness of the problem of stigma and discrimination
toward injecting drug users as well as support and commitment to stop
stigma and discrimination.
c) Get service providers, law enforcement agents, rehabilitation center
officials, and the community to start developing new codes of practice for
how they counsel, test, and treat IDU/drug addict patients.
A key aim of the toolkit is to help injecting drug users break out of a life on
the margins, build improved relations with their families and communities,
reassert their rights, protect themselves and their partner from HIV and
other STIs, and get better access to health services.
Type of
Document:
The toolkit is a collection of educational exercises to explore, understand,
and challenge stigma and discrimination toward IDUs.
Audience
Intended:
Facilitators of training; to be used by individuals and organizations that are
working to stop stigma and discrimination toward injecting drug users. One
of the aims of the toolkit is to help its key target audiences, including health
care workers, police officers, and community members, become more aware
of stigma and discrimination toward IDUs and what can be done to change
it.
Population
Experiencing
Stigma and/or
Discrimination:
IDUs.
Stigma and/or
Discrimination:
Both - and distinction explained, but more on stigma and usually combined.
Assess and/or
Address:
Address.
Implementation: The toolkit comprises a collection of optional exercises. These exercises can
be used with a single group (e.g., health workers or drug users) or with a
mix of groups. The toolkit can be used to hold a five-day workshop or a
single community meeting; to conduct short sessions once a week over
several weeks (say to an IDU support group or the staff of a health facility);
or to conduct two or three exercises as a way to introduce a longer and
broader training program on HIV and AIDS.
Comments: Part of the "Understanding and Challenging" series, see other entries.
Link: http://www.icrw.org/files/publications/Toolkit%20for%20action%20-
%20Reducing%20stigma%20toward%20drug%20addiction%20and%20HI
64
V%20in%20Vietnam.PDF
34.
Name: Measuring up: HIV-related advocacy evaluation training pack
Organization
(Year):
International HIV/AIDS Alliance
(2010)
Aim: The guides aim to: (1) help users to identify and confront the challenges
faced by community-based organizations evaluating HIV-related advocacy;
(2) introduce new thinking for designing advocacy evaluations; (3) give
users the opportunity to apply some aspects of the evaluation design process
to their specific contexts (4) make users aware that advocacy evaluation is a
fast-growing and evolving field, with a large number of publications on
advocacy evaluation design, approaches and methods available via the
Internet and summarized in the resources section of the learner’s guide.
Type of
Document:
A pack of two documents, a guide for facilitators, and a guide for learners.
Audience
Intended:
The guide is a resource for leaders, advocacy and monitoring and evaluation
staff of civil society organizations (including networks) who are involved in
designing, implementing and assessing advocacy projects at different levels
– international, national and sub-national. Leaders of networks of key
populations are likely to find this guide particularly relevant and helpful.
These leaders may use the facilitators guide to run participatory workshops
with NGOs/CBOs responding to HIV/AIDS, and ostensibly with other
interested advocates.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Both.
Implementation: The facilitator’s guide suggests activities for a three-day skills-building
workshop and one-day learner’s workshop that aim to introduce the content
and key messages of the learner’s guide. The workshop aims to build on the
existing capacity of civil society organization staff evaluating their
advocacy work on HIV-related issues in resource-limited settings.
Comments: Mainly focused on evaluation of advocacy—very little directly on
65
stigma/discrimination (though that may be a part of the advocacy efforts
being evaluated).
Link: http://www.aidsalliance.org/assets/000/000/686/477-Measuring-Up-A-
Guide-for-Learners_original.pdf?1406296305
35.
Name: Recommendation Concerning HIV and AIDS and the World of Work
Organization
(Year):
International Labour Organisation
(2010)
Aim: The Recommendation reflects the need to strengthen workplace prevention
efforts and to facilitate access to treatment for persons living with or
affected by HIV and AIDS. It calls for the design and implementation of
national tripartite workplace policies and programs on HIV and AIDS to be
integrated into overall national policies and strategies on HIV and AIDS
and on development and social protection. It calls for respect for the
fundamental human rights of all workers, including observance of the
principle of gender equality and the right to be free from compulsory testing
and disclosure of HIV status, while encouraging everyone to undertake
voluntary confidential HIV counseling and testing as early as possible. The
Recommendation also invites member States to implement its provisions
through amendment or adoption of national legislation where appropriate.
Type of
Document:
Normative instrument--recommendation No. 200 concerning HIV/AIDS
and the world of work.
Audience
Intended:
ILO Member states.
Population
Experiencing
Stigma and/or
Discrimination:
Those impacted by HIV/AIDS in both formal and informal work
environments (including health care settings).
Stigma and/or
Discrimination:
Both, and both defined.
Assess and/or
Address:
Address.
Implementation: N/A
Comments: Definitions and general principles are useful. This is particularly relevant
when considering health care settings as workplaces for the health
workforce. As such, this is useful for anyone affected by HIV working in
health care settings.
66
Link: http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---
ilo_aids/documents/normativeinstrument/wcms_194088.pdf
36.
Name: When Health Care Isn't Caring: Lambda Legal’s Survey on Discrimination
Against LGBT People and People Living with HIV
Organization
(Year):
Lambda Legal
(2010)
Aim: To examine refusal of care and barriers to health care among LGBT and
HIV communities on a national scale.
Type of
Document:
Report and analysis of survey on discrimination against LGBT people and
people living with HIV.
Audience
Intended/:
Policymakers, researchers, advocates, individuals and organizations,
healthcare institutions.
Population
Experiencing
Stigma and/or
Discrimination:
LGBT people and living with HIV.
Stigma and/or
Discrimination:
Discrimination.
Assess and/or
Address:
Both (survey is assessment focused, but recommendations and document
also address)
Implementation: Survey conducted and results summarized here; key example of
discrimination-focused assessment.
Comments: US-centric; firmly focused on discrimination.
Link: https://www.lambdalegal.org/sites/default/files/publications/downloads/whc
ic-report_when-health-care-isnt-caring_1.pdf
37.
Name: We Are All in the Same Boat: Using Art and Creative Approaches with
Young People to Tackle HIV related Stigma
Organization
(Year):
UNESCO and International HIV/AIDS Alliance
(2010)
Aim: To educate young people about HIV stigma and discrimination and build
their skills, confidence and commitment to act against stigma.
Type of
Document:
Toolkit on HIV stigma for young people. A set of ideas on how to use art
and creative approaches to build a new understanding about HIV stigma and
human rights, and on how young people can work together to challenge
67
stigma and discrimination.
Audience
Intended
The teacher, youth worker, youth leader, peer educator or anyone working
with youth groups, who can then use the approaches--including art, games
and exercises--with young people aged 12-15 years both in and out of
school.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV, and particularly young people living with HIV.
Stigma and/or
Discrimination:
Both, mostly stigma but separately defined.
Assess and/or
Address:
Address.
Implementation: The toolkit uses different art forms and creative activities – drama and role
playing, games, drumming, dance, puppets, story telling, pictures, drawing
and collages – to spark new thinking about HIV stigma, change attitudes
and challenge young people to do something.
Comments: Part of the rationale for the toolkit includes PLHIV being mistreated at
clinics and having difficulty accessing health services.
Link: http://unesdoc.unesco.org/images/0018/001892/189249E.pdf
38.
Name: Measuring the Degree of HIV-related Stigma and Discrimination in Health
Facilities and Providers
Organization
(Year):
USAID/Health Policy Initiative
(2010)
Aim: To assess the validity of items designed to measure the key drivers of
stigma.
Type of
Document:
This working report presents the findings from an internet-based survey
designed to validate the items in the Health Facility and Provider Stigma
Measurement Tool.
Audience
Intended:
Stigma researchers, healthcare workers, healthcare administrators,
evaluators.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
68
Stigma and/or
Discrimination:
Stigma - both listed but focus is clear.
Assess and/or
Address:
Assess.
Implementation: N/A (report), but recommendations and next steps may have implications
for implementation of future tools.
Comments: Report of the development of the stigma index and measurement tool,
aimed at researchers and healthcare providers. Note that this was part of
developing the ‘Comprehensive Package for Reducing Stigma and
Discrimination in Health Facilities’ (Number 2 in this inventory). This
document underpins the validity of the more recent tools, which are what
interested people should use.
Link: http://www.healthpolicyinitiative.com/Publications/Documents/1312_1_He
alth_Facility_and_Provider_Stigma_Measurement_Tool_.pdf
2009
39.
Name: Diagnosis of the Stigma and Discrimination Situation of People Living with
and Vulnerable to HIV and AIDS: Health Providers and Health Facilities
(in Spanish)
Organization
(Year):
Consorcio Miradas y Voces
(2009)
Aim: To address the evidence gap regarding discrimination in care and services
for PLHIV and people vulnerable to HIV, particularly in health care
settings.
Type of
Document:
Report, detailing a conceptual framework, methodology, and results. Tools
for data collection are also included in the annex.
Audience
Intended:
The Ministry of Health, health personnel, researchers and advocates. Two
populations were included in the study in two separate questionnaires:
health professionals and PLHIV.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV and other vulnerable populations, including MSM.
Stigma and/or
Discrimination:
Both, and typically connected.
Assess and/or Assess.
69
Address:
Implementation: The study was conducted in the cities of Lima, Callao, Ica and Pucallpa.
Comments: Peru focus. The data collection tools in the annex are interesting for this
work.
Link: Soft copy available
40.
Name: Rapid Assessment Tool for Sexual & Reproductive Health and HIV
Linkages: A Generic Guide
Organization
(Year):
IPPF, UNFPA, WHO, UNAIDS, GNP+, ICW and Young Positives.
(2009)
Aim: To assess HIV and SRH bi-directional linkages at the policy, systems and
service-delivery levels. It is intended also to identify gaps, and ultimately
contribute to the development of country-specific action plans to forge and
strengthen these linkages. While this tool focuses primarily on the health
sector it can be adapted to cover other sectors (education, social services,
and labour).
Type of
Document:
This generic tool covers a broad range of linkages issues, such as policy,
systems and services. By design, it aims to provide a guide for assessing
linkages that can be adapted as needed to regional or national contexts
based on a number of factors. Countries are encouraged to review the
questions and the scope of the assessment and modify it according to the
local situation. There are specific instruments covering three sections: (1)
Policy; (2) Systems; and (3) Clinical Service Delivery, which includes a
Provider Interview form and a Client Exit Interview form.
Audience
Intended:
For use by countries, or in guiding national level responses. The results of
the needs assessment tool are particularly relevant to policy-makers,
programme managers, service providers, clients, donors and partners in
health.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV and vulnerable populations.
Stigma and/or
Discrimination:
Both; discrimination usually connected to stigma, and a few probes of
stigma on its own.
Assess and/or Assess
70
Address:
Implementation: The tool can be used as a “standalone” activity or can be integrated into a
larger review of the national response. It focuses on questions which can be
answered in desk reviews and individual or group interviews (Policy and
Systems sections), and individual interviews of various service providers
and clients (Service delivery section). These approaches can be
supplemented with a range of other research methodologies, including:
observations of services, focus group discussions among policy-makers,
service providers, and clients, collection of data from clinic records, and
“mystery client” surveys. The tool is suggested for use in an assessment of
policies, systems and services related to SRH and HIV linkages. The
questions provide a guide to assessing these linkages but are not meant to be
exhaustive. The assessment should include group interviews with the chief
current and past policy and programme decision-makers, donors, and
development partners, and individual interviews with providers and clients
from a wide range of services. Attention must be paid to ensure that the
assessment focuses equally on the SRH and HIV components. The
assessment should include members of the national HIV coordination body.
Comments: References HIV-based discrimination in relation to legal and policy
measures, and in the preliminary questionnaire and client exit interview.
Link: http://www.gnpplus.net/assets/wbb_file_updown/2022/Rapid%20Assessme
nt%20Tool%20for%20Sexual%20&%20Reproductive%20Health%20and%
20HIV%20Linkages.pdf
41.
Name: Template for “Human Rights in Patient Care, A Practitioner Guide”
Organization
(Year):
Open Society Foundations (OSF)
(2009)
Aim: To strengthen awareness of existing legal tools that can be used to remedy
abuses in patient care.
Type of
Document:
Designed as a practical, “how to” manual for lawyers, it aims to provide an
understanding of how to use legal tools to protect basic rights in the
delivery of health services. The guide systematically reviews the diverse
constitutional provisions, statutes, regulations, by-laws, and orders
applicable to patients and health care providers and categorizes them by
right or responsibility. It highlights examples and actual cases argued by
lawyers.
71
Audience
Intended:
Lawyers working to protect human rights in health care settings.
Population
Experiencing
Stigma and/or
Discrimination:
Patients (though may be more specific in each country).
Stigma and/or
Discrimination:
Discrimination.
Assess and/or
Address:
Address.
Implementation: N/A
Comments: This tool covers health much more broadly than HIV. Non-discrimination is
discussed broadly in the template. The entry point is the
discrimination/legal angle as opposed to the stigma/sensitization angle.
Link: http://www.health-rights.org/guides/pginto/
42.
Name: Understanding and Challenging TB Stigma: Toolkit for Action
Organization
(Year):
Zambart Project and International HIV/AIDS Alliance
(2009)
Aim: To address TB stigma at multiple levels.
Type of
Document:
Module both as a standalone and as part of the broader “Understanding and
Challenge” series (see above). The exercises in the module were developed
with TB patients, health workers and community TB support staff and can
be used with a variety of audiences to help tackle TB stigma.
Audience
Intended:
The module was written by and for trainers. It has been designed to help
trainers plan and organize participatory educational sessions with
community leaders or organized groups to raise awareness and promote
practical action to challenge HIV and TB stigma and discrimination.
Population
Experiencing
Stigma and/or
Discrimination:
People living with TB, and also people susceptible to TB, including PLHIV.
Stigma and/or
Discrimination:
Both, mostly stigma but separately defined.
Assess and/or
Address:
Address.
Implementation: The exercises in this module were developed with TB patients, health
72
workers and community TB support staff and can be used with a variety of
audiences to help to tackle TB stigma, including community leaders,
medical staff, TB patients and family members, TB program volunteers,
support groups and so on. During the testing of the exercises, trainers
agreed that using them in a mixed group, for example health workers
alongside TB patients, resulted in higher levels of understanding and
experience sharing.
Comments: Part of the "Understanding and Challenging" series, see other entries.
Link: http://r4d.dfid.gov.uk/PDF/Outputs/Targets_RPC/TB_and_Stigma_May09.
2008
43.
Name: Sexual and Reproductive Health of Women and Adolescent Girls Living
With HIV: Guidance for health managers, health workers, and activists
Organization
(Year):
Engender Health, UNFPA, Packard Foundation, et al.
(2008)
Aim: To provide contributions toward guaranteeing that the right to health and
the right to SRH of women and adolescent girls living with HIV and AIDS
are totally and integrally protected, promoted, and guaranteed.
Type of
Document:
Guidance document. It functions as a report and set of recommendations,
with key concepts
Audience
Intended:
Organizations, researchers, activists, health managers at country level--
generally applicable principles.
Population
Experiencing
Stigma and/or
Discrimination:
Women and Adolescent Girls living with HIV.
Stigma and/or
Discrimination:
Both, but from rights framing.
Assess and/or
Address:
Address.
Implementation: Operates as a set of recommendations.
Comments: Rights-based approach: includes "Reviewing all national and international
literature on SRH programs and projects and on human rights that had any
relation to women and adolescent girls living with HIV".
Link: https://www.engenderhealth.org/files/pubs/hiv-aids-stis/english-srh-
73
guidance-final.pdf
44.
Name: Strengthening the Quality of HIV/AIDS Counselling: Training Course for
HIV/AIDS Voluntary Counselling and Testing Service Providers
Organization
(Year):
Institute for Reproductive Health, Population Services International, and
Pan American Social Marketing Organisation
(2008)
Aim: To (1) improve quality, access and utilization of VCT services for
HIV/AIDS; and (2) reduce stigma and discrimination in highly
vulnerable populations such as commercial sex workers (CSW) and
men who have sex with men (MSM). One of the training objectives
is “how to recognize stigma and discrimination”.
Type of
Document:
Training Manual. The two day course provides: (a) the normative and
technical framework to sensitize health care providers about the VCT
process as well as the stigma and discrimination that exists at their work
sites; (b) a space for reflection about their own attitudes and behaviors; and
(c) opportunities for hands-on practical experience.
Audience
Intended:
This appears to be a resource for trainers to train healthcare providers but
review was limited by inability to access the full document.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV, commercial sex workers, MSM
Stigma and/or
Discrimination:
Both
Assess and/or
Address:
Address
Implementation: Two day course, including participatory activities, role plays, counseling
demonstrations and group activities.
Comments: Unfortunately, link to PDF broken, so review limited to description on
website.
Link: http://www.comminit.com/global/content/strengthening-quality-hivaids-
counseling-training-course-hivaids-voluntary-counseling-an
45.
Name: Safe and Friendly Health Facility: Trainers’ Guide (Vietnam)
74
Organization
(Year):
Institute for Social Development Studies and ICRW; Horizons Program and
Population Council; USAID
(2008)
Aim: To help create a safe and friendly hospital environment, one in which health
workers and patients feel physically safe and psychologically safe; Build
more respect, caring and support for people living with HIV; Develop the
practical skills to implement Universal Precautions in a systematic way;
Develop a code of practice for implementing stigma free practices and
Universal Precautions.
Type of
Document:
Trainer's guide to help facilitators train staff of health facilities, trainers are
to train all staff including administrative and support staff.
Audience
Intended:
Facilitators of training, to work directly with health facility staff in a non-
challenging/non-criticizing way.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Both - and distinction explained, but more on stigma.
Assess and/or
Address:
Address.
Implementation: Emphasizes avoiding placing blame on health workers.
Comments: Vietnam focus. This trainer’s guide functions as tool component, see also
report on “Improving Hospital-based Quality of Care in Vietnam by
Reducing HIV-related Stigma and Discrimination”:
http://www.icrw.org/files/publications/Improving-hospital-based-quality-of-
care-in-Vietnam-by-reducing-HIV-related-stigma-and-discrimination.pdf
Link: http://www.icrw.org/files/publications/Safe-and-Friendly-Health-Facility-
Trainers-Guide.pdf
46.
Name: Working Module for Healthcare Providers: How to Reduce Stigma and
Discrimination
Organization
(Year):
CARE Peru
(2008)
Aim: To strengthen national and regional responses directed at the
prevention and control of HIV and AIDS; to reduce the social impact of
HIV, reducing stigma and discrimination against people with
75
HIV and AIDS and vulnerable populations; and to promote awareness,
particularly among healthcare providers.
Type of
Document:
A training document aimed at awareness, reflection, and rights promotion,
including training on the link between stigma and discrimination in health
facilities against people living with HIV, or to those thought to have HIV,
and reflection on its causes and consequences.
Audience
Intended:
Trainers can train health workers, with all health staff in a facility.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Both, and both defined.
Assess and/or
Address:
Address.
Implementation: 2-4 day workshop. Trainers can adapt the program as needed for the
audience.
Comments: Directly focused on stigma and discrimination.
Link: Soft copy available
2007
47.
Name: HIV/AIDS Stigma and Discrimination in Caribbean Healthcare Settings:
Trigger Scenarios
Organization
(Year):
Caribbean HIV/AIDS Regional Training Network
(2007)
Aim: To increase awareness of patients’ basic rights and human rights; Highlight
the role of institutional policy in preventing stigma and discrimination;
Provide opportunities to discuss basic HIV/AIDS transmission and
prevention; Dispel myths and misinformation about HIV/AIDS
transmission; Provide a forum to discuss values-based causes of stigma and
discrimination; Model behaviors that can reduce stigma and discrimination;
Give a human face to the stories of people living with HIV and AIDS
(PLWHA)
Type of
Document:
Facilitator Guide for HIV/AIDS Stigma and Discrimination in Caribbean
Health Care Settings: Trigger Scenarios and Facilitator Guide. 13 short
76
video scenarios to trigger discussion on stigma-related situations involving
health care workers, clients, and community members in Caribbean health
care settings. Part of a series of HIV training videos.
Audience
Intended:
For experienced, knowledgeable facilitators to administer to health care
workers.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Both - and distinction explained.
Assess and/or
Address:
Address.
Implementation: Adaptable for different audiences. See Annex B for implementation tips and
more depth. Appendices also useful.
Comments: Just the facilitator guide: no link to actual videos. The last question in most
scenarios is specific to policies in place.
Link: http://pdf.usaid.gov/pdf_docs/PBAAC056.pdf
48.
Name: Taking Action Against HIV Stigma and Discrimination (Guidance
Document and Supporting Resources)
Organization
(Year):
Department for International Development (UK); International Center for
Research on Women (ICRW)
(2007)
Aim: To advance efforts towards effective, scaled-up interventions that can
generate broad reductions in stigma and discrimination.
Type of
Document:
Paper highlighting best practice responses to stigma and discrimination and
guidance on building evidence and accelerating action for change
Audience
Intended:
DFID staff (UK) and others working on HIV and AIDS, likely broad
interest.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Both.
Assess and/or Address.
77
Address:
Implementation: N/A
Comments: Guidance document, but may be useful as framework for a tool. Additional
background and supporting resources. Case study on health care
discrimination in India on p.28
Link: http://www.icrw.org/files/publications/DFID-Taking-Action-Against-HIV-
Stigma-and-Discrimination.pdf
49.
Name: Adherence Support Worker Training Materials
Organization
(Year):
FHI 360
(2007)
Aim: This training will teach community volunteers — called adherence support
workers (ASWs) — to work alongside nurses and doctors as part of the
clinical team at ART clinics.
Objectives include: Increasing access to and use of HIV counseling and
testing services; Increasing access to and use of interventions for preventing
mother-to-child transmission of HIV; Increasing access to and
strengthening delivery of clinical care for HIV/AIDS, including diagnosis
and prevention and management of opportunistic infections and other HIV-
related conditions; Increasing access to and strengthening delivery of ART
services at the provincial and district levels.
Type of
Document:
Training materials (both facilitator's guide and participants’ guide) for
training adherence support workers on ART clinical teams.
Audience
Intended:
Facilitators to train Adherence Support Workers, who assist and report to
adherence counselors at health center level.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Both, and both defined.
Assess and/or
Address:
Address (with limited assessment of participant knowledge at beginning).
Implementation: Ten-day training. The training includes technical information as well as
techniques for relationship building and counseling skills. The modules
include didactic sessions as well as role plays and group exercises.
Information on stigma and discrimination is interspersed throughout the
78
materials, and day one of the proposed agenda includes 1.5 hours of
discussion specifically exploring the concepts of stigma and discrimination
as a part of the overall session on introductions and expectations.
Comments: Zambia-focus.
Link: http://www.fhi360.org/sites/default/files/media/documents/Adherence%20S
upport%20Worker%20Training%20Materials%20-
%20Facilitators%20Guide.pdf
50.
Name: A Guide to Nursing Care of People Living with HIV/AIDS (PDF in Arabic)
Organization
(Year):
FHI 360
(2007)
Aim: To build the knowledge and capacity of nurses who work with people living
with HIV or AIDS and to reduce stigma and discrimination toward them
from health care workers.
Type of
Document:
A guide, with topics that include prevention, care and support; nursing
practices; and treatment and control of opportunistic infections.
Audience
Intended:
Nurses.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Appears to be both--see comments.
Assess and/or
Address:
Address.
Implementation:
Comments: Unfortunately PDF only available in Arabic, so review limited to FHI 360
page description.
Link: http://www.fhi360.org/resource/guide-nursing-care-people-living-hivaids-
pdf-arabic
51.
Name: Reducing HIV Stigma and Gender Based Violence Toolkit for Health Care
Providers in India
Organization
(Year):
International Center for Research on Women (ICRW)
(2007)
79
Aim: To prevent the spread of HIV and AIDS by making it easier for people
living with HIV to access health services, disclose their status and prevent
the spread of HIV to others, while also eliminating some of the barriers that
impede the ability of uninfected women to protect themselves from the
virus.
Type of
Document:
Toolkit for the trainers of the healthcare providers, to be used in planning
and organizing educational sessions with healthcare providers to challenge
HIV-related stigma and GBV.
Audience
Intended:
For the trainers of the healthcare providers, to be used in planning and
organizing educational sessions with healthcare providers to challenge HIV-
related stigma and GBV.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV, people subject to stigma and GBV in India.
Stigma and/or
Discrimination:
Both, but stigma focus.
Assess and/or
Address:
Address.
Implementation: A collection of participatory educational exercises for educating health care
providers on the issues of stigma and gender-based violence. Trainers can
select from the exercises to plan their own courses for different types of
health care providers. The modules use a learner-centered, participatory
approach to training—one built around discussion and small-group
activities.
Comments: India focus.
Link: http://www.icrw.org/files/publications/Reducing-HIV-Stigma-and-Gender-
Based-Violence-Toolkit-for-Health-Care-Providers-in-India.pdf
52.
Name: Reducing HIV Stigma and Discrimination: a critical part of national AIDS
programs; A resource for national stakeholders in the HIV response
Organization
(Year):
UNAIDS
(2007)
Aim: To demonstrate how governments, the UN system, donors and civil society
can make the reduction of HIV-related stigma and discrimination central in
the national response to AIDS.
Type of A resource that presents strategies, program examples and research
80
Document: findings.
Audience
Intended:
Primarily national stakeholders, but lists governments, UN system, donors,
civil society.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Both, mainly combined, stigma focus.
Assess and/or
Address:
Address.
Implementation: N/A
Comments: More a general strategy tool than a narrow training tool.
Link: http://data.unaids.org/pub/Report/2008/jc1521_stigmatisation_en.pdf
2006
53.
Name: Sexual and Reproductive Health for HIV-Positive Women and Adolescent
Girls: Manual for Trainers and Programme Managers
Organization
(Year):
Engender Health
(2006)
Aim: To enable health workers to address the SRH needs of HIV-positive women
and adolescent girls by offering comprehensive SRH services within their
own particular service-delivery setting.
Type of
Document:
Manual that provides information and structure for a four-day training and
two-day planning workshop that will enable program managers and health
workers in resource-constrained settings to offer comprehensive, non-
judgmental, and quality care and support to HIV-positive women and
adolescent girls in the local context.
Audience
Intended:
This manual is designed for use by skilled, experienced trainers. This
curriculum can be used to train any SRH and HIV/AIDS health worker. The
term health workers is used here to refer to the staff who provide clinical
care, counseling, or other support services on-site or through outreach.
Population
Experiencing
Stigma and/or
HIV positive women and adolescent girls; also urges male involvement.
81
Discrimination:
Stigma and/or
Discrimination:
Both, generally discrimination grouped with stigma.
Assess and/or
Address:
Address.
Implementation: A team of at least two trainers is necessary for this intensive workshop. As
one trainer facilitates a session, the other(s) can record information on
flipcharts, monitor time, help keep the discussion on track with the session
objectives, monitor small-group work, and act in demonstration role-plays.
It is imperative for the trainers to have extensive experience either in
counseling or in counseling training. Four-day training and two-day
planning workshop.
Comments: Role play scenarios and key ideas interesting.
Link: http://www.iwtc.org/ideas/7_adolescent.pdf
54.
Name: Tools together now! 100 participatory tools to mobilise communities for
HIV/AIDS
Organization
(Year):
International HIV/AIDS Alliance
(2006)
Aim: To help organizations and community groups mobilize and work together to
address HIV/AIDS issues. These issues may relate to HIV prevention,
treatment, care and support for people living with HIV/AIDS, or mitigating
the negative impact of HIV/AIDS on affected communities.
Type of
Document:
This toolkit provides a selection of 100 participatory learning and action
(PLA) tools. PLA tools are interactive activities which enable communities
and organizations to learn together about a HIV/AIDS in their community,
develop a plan, act on it and evaluate and reflect on how it went.
Audience
Intended:
Organizations and community groups can use them to assess the local
HIV/AIDS situation, plan, act, monitor, evaluate, reflect or scale up
HIV/AIDS activities. People working directly with communities affected by
HIV/AIDS will find these tools most helpful. However, any organization
working on HIV/AIDS should find these tools useful for their work.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or Both, but specific tool included on mapping stigma.
82
Discrimination:
Assess and/or
Address:
Both.
Implementation: This toolkit was specifically designed for communities and organizations to
use alongside “All Together Now! Community Mobilization for
HIV/AIDS” (not included in current review as toolkit is most relevant).
Comments: See in particular tool 9 on “Mapping Stigma.”
Link: http://www.aidsalliance.org/assets/000/000/370/229-Tools-together-
now_original.pdf?1405520036
2005
55.
Name: The PLHA Friendly Checklist: A Self Assessment Tool for Hospitals and
Other Medical Institutions Caring for People Living with HIV/AIDS
Organization
(Year):
Horizons Project/Population Council and SHARAN
(2005)
Aim: The PLHA-friendly Achievement Checklist is intended as a self assessment
tool for managers to use in gauging how well their facility (hospital, clinic,
or department) reaches, serves, and treats HIV-positive patients.
Type of
Document:
Self assessment checklist.
Audience
Intended:
For managers to use in gauging how well their facility (hospital, clinic, or
department) reaches, serves, and treats HIV-positive patients. This gives
managers an opportunity to identify institutional strengths and weaknesses,
consider ways to address the weaknesses, and later to assess progress
toward “PLHA-friendliness.”
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV
Stigma and/or
Discrimination:
Both, but connected and single reference in passing.
Assess and/or
Address:
Address.
Implementation: The Checklist is designed in a simple format that can be readily adapted for
each unique context. It can be used by individual managers or by groups of
managers and/or staff. It can be applied to large hospitals, clinics, or
83
specific departments
Comments: Focus is on PLHIV-friendly services more broadly; stigma and
discrimination are mentioned briefly in passing.
Link: http://www.popcouncil.org/uploads/pdfs/horizons/pfechklst.pdf
2004
56.
Name: Reducing Stigma and Discrimination Related to HIV and AIDS: Training
for Health Care Workers
Organization
(Year):
Engender Health
(2004)
Aim: To modify health care workers’ attitudes while giving them practical
knowledge and tools to both assure client rights and meet their own needs
for a safe work environment.
Type of
Document:
Manual for use as on-site training for all staff of a healthcare facility.
Contains standard precautions and training aimed at minimizing stigma and
discrimination. Questions, discussions, training tips and ideas to consider,
Also contains participant's handbook as second document.
Audience
Intended:
Healthcare workers and all surrounding staff in health facility (e.g.
gardeners, reception staff).
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV
Stigma and/or
Discrimination:
Both
Assess and/or
Address:
Address
Implementation: This training is best conducted as an on-site training with all staff of the
health care facility, including laboratory staff, cleaners, guards, gardeners,
receptionists, nurses, midwives, physicians, and other health workers…if an
on-site training is not possible, the trainers should develop a plan for
ensuring that the knowledge and process is diffused from the training
participants to other staff at the facility where they work...[training takes] at
least two days, depending on the group (six days if more intensive training
on infection prevention practices is desired).
Comments: Contains some “case studies" with answer keys.
Link: https://www.engenderhealth.org/files/pubs/hiv-aids-
84
stis/reducing_stigma_trainer_english.pdf
2003
57.
Name: COPE Handbook: A Process for Improving Quality in Health Services
Organization
(Year):
Engender Health
(2003)
Aim: COPE, which stands for “client-oriented, provider-efficient” services, is a
process that helps health care staff continuously improve the quality and
efficiency of services provided at their facility and make services more
responsive to clients’ needs.
Type of
Document:
A set of tools, including a self-assessment guide, a client-interview guide,
client-flow analysis, and an action plan. They operate as a means for
reproductive healthcare staff to assess their own work, so as to identify
problems in the facility and local solutions to those problems. Forms,
success examples, talking points, etc.
Audience
Intended:
Two types of facilitators (external and on-site) support the COPE self
assessment process, which is ongoing and should engage all staff at a health
facility.
Population
Experiencing
Stigma and/or
Discrimination: Patients, healthcare consumers.
Stigma and/or
Discrimination:
Stigma (briefly, generally in connection with HIV), sex based
discrimination mentioned once regarding access to services.
Assess and/or
Address: Both.
Implementation: Site preparation, introductory meetings, application of cope tools (usually
over 1-3 days), action plan, and then subsequent actions (including
measurement of the facility’s progress over time).
Comments: Not a lot on stigma and discrimination, but emphasis on staff involvement
and ownership is notable, as is the potentially on-going process of COPE
and measurement of the facility’s progress.
Link: https://www.engenderhealth.org/files/pubs/qi/handbook/cope_handbook-
a.pdf
58.
85
Name: Understanding and Challenging HIV Stigma: Toolkit for Action
Organization
(Year):
ICRW
(2003)
Aim: To provide people working in the AIDS field--especially the “front-line”
workers--with a set of flexible educational materials to raise their own
understanding and help them facilitate awareness raising with community
groups. The aim is to help people at all levels understand stigma and what it
means, why it is an important issue, what are its root causes and develop
strategies to challenge stigma and discrimination.
Type of
Document:
Trainer’s guide. The Toolkit is a resource collection of participatory
educational exercises for use in raising awareness and promoting action to
challenge HIV stigma.
Audience
Intended:
"Front-line" workers in the AIDS field, for their own education and to help
facilitate awareness; additionally NGOs, other AIDS professionals and
community members. Trainers can select from the exercises to plan their
own courses for different target groups both AIDS professionals and
community groups.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination: Stigma (discrimination often connected, but no discrete treatment).
Assess and/or
Address: Address.
Implementation: See p. iii for How to Use the Toolkit. It is meant to be participatory (not
lectures) and not standardized--facilitators are meant to pick excercises and
create their own "custom" package of training to fit the needs of the group.
Idea is to build awareness and move towards action. Also directs NGOs and
AIDS organizations to work through the materials, and provide feedback as
to what worked and didn't work.
Comments: The "mother document" for each of the understanding and challenging
adaptations included in this inventory.
Link: http://www.icrw.org/sites/default/files/publications/Understanding-and-
Challenging-HIV-Stigma-Toolkit-for-Action.pdf
2002
59.
86
Name: Implementing the ILO Code of Practice on HIV/AIDS and the World of
Work: An Educational and Training Manual
Organization
(Year):
International Labour Organisation
(2002)
Aim: To help the ILO’s partners understand the issues and apply the ILO Code of
Practice on HIV/AIDS and the world of work.
Type of
Document:
This manual is a source of information on HIV/AIDS and the world of
work, a reference guide to the ILO Code of Practice and its application in
policy development, and a tool for training. Modules contain several types
of materials, including: presentation of the issues, with particular reference
to the world of work and the ILO Code of Practice; learning activities
(group work, role play etc.); case studies; extracts, models and samples of
legislation, policies and collective agreements; references.
Audience
Intended:
The Code of Practice identifies a range of groups with a role in training,
including managers, personnel officers, peer educators, workers’
representatives, health and safety officers, and labor inspectors. All of these,
and others, should find helpful information and learning activities in this
manual.
Population
Experiencing
Stigma and/or
Discrimination:
Those affected by HIV in the workplace.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Address.
Implementation: It is ideal to use as a reference when planning a policy or strategy. You can
work through the whole book or parts of it on your own, in a meeting or as
a team exercise. You can see what other people have done, consider
whether it could be adapted to your situation, and follow suggestions.
Comments: Case studies interesting.
Link: http://www.ilo.org/wcmsp5/groups/public/---dgreports/---
dcomm/documents/publication/kd00131.pdf
Undated publications
60.
Name: Dealing with problems [re HIV discrimination in health care]
87
Organization
(Year):
NAM (formerly National AIDS Manual)
(Undated--reference from 2010)
Aim: [Reviewer provided: to provide information on dealing with HIV related
discrimination].
Type of
Document:
Website with some brief resources and a description of HIV-related
discrimination in health care settings. Three methods for dealing with
discrimination are described: complaining directly to the person or
organization they believe has discriminated against them; asking someone
else to help through mediation or conciliation; making a claim in court.
Audience
Intended:
PLHIV and advocates.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Discrimination.
Assess and/or
Address:
Address.
Implementation: N/A
Comments: UK focus, distinctly aimed at discrimination and probably accessible to
many.
Link: http://www.aidsmap.com/Dealing-with-problems/page/1501232/
61.
Name: “It’s My Turn!’ HIV Prevention and Care Training Manual and Tools for
Peer Educators of “Men who have Sex with Men”
Organization
(Year):
FHI 360
(Undated)
Aim: To help address sexual health, HIV and other STI challenges experienced
by MSM in Ghana.
Type of
Document:
A training manual and set of tools intended as a resource for organizations
working with this most-at-risk population. Three parts: (1) session plans for
training MSM peer educators, (2) tools for MSM peer educators, (3)
continuing education and supportive supervision.
Audience Initial training of peer educators and supervisors on this resource is
88
Intended: required, followed by periodic continuing education. A participatory
learning approach is presented; the participants — whether peer educators
or supervisors — will have much to share. They can then train peers.
Population
Experiencing
Stigma and/or
Discrimination:
MSM.
Stigma and/or
Discrimination:
Both.
Assess and/or
Address:
Address.
Implementation: Depending on your audience, you will pick and choose what is relevant in
this resource to make your own training program. It is not necessary for a
trainer to start at the beginning and work his way through the entire manual.
Samples are 5-day trainings.
Comments: Ghana focus.
Link: http://www.fhi360.org/sites/default/files/media/documents/Manual%20MS
M%20Peer%20Educators_0.pdf
62.
Name: Virtual Office of Human Rights and Legal Services
Organization
(Year):
Letra Ese
(Undated)
Aim: To facilitate access to counseling and support in cases of discrimination
based on HIV status, sexual orientation and gender identity.
Type of
Document:
Online platform of community workers and lawyers that provide support
services, counseling and legal advice for PLHIV who have been
discriminated against or who have experienced rights violations.
Audience
Intended:
People who feel they have been discriminated against can seek legal
advice, receive support and assistance in filing complaints with human
rights watchdogs, at the local and federal level, and access a digital library,
focused on human rights, sexual diversity and HIV.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV, LGBT people.
89
Stigma and/or
Discrimination:
Discrimination.
Assess and/or
Address:
Address.
Implementation: Through the website www.letraese-ddhh.com, people can receive legal
consultations and describe specific cases for timely advice and support, and
learn how to make complaints and access other legal remedies. Services are
free and confidential.
Comments: Mexico focus.
Link: www.letraese-ddhh.com
63.
Name: Know It, Prove It, Change It: A Rights Curriculum For Grassroots Groups
Organization
(Year):
Asia Catalyst, Thai AIDS Treatment Action Group (TTAG) and Dongjen
Center for Human Rights Education and Action
(Undated)
Aim: To help community based organizations in communities affected by
HIV/AIDS to understand their basic rights, to document rights abuses, and
to design and implement advocacy campaigns.
Type of
Document:
There are three ‘books’: knowing human rights, documenting human rights
abuses, and advocating for change. Each book includes a trainer’s manual,
which describes the steps to take; and a trainers’ supplement, which has
lesson plans, sample exercises, and templates to use in a training or
workshop.
Audience
Intended:
Community-based organizations and/or trainers for use with community-
based organizations.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Discrimination.
Assess and/or
Address:
Address.
Implementation: The ‘training manual’ can be used by individuals for self-training, while the
‘trainers’ supplement’ is designed for use by trainers to carry out training
workshops for people working in community-based organizations. It is
recommended that workshops do not exceed 10-20 particpants. Workshops
90
based on individual modules usually need about 45-60 minutes. The full
training covering all three ‘books’ would take multiple days.
Comments: About human rights relating to HIV: much broader than discrimination.
Link: http://asiacatalyst.org/resources/cbo-resources/
64.
Name: Human Rights Service Modules
Organization
(Year):
Letra Ese
(Undated)
Aim: To support people with HIV who have been discriminated against in health
services and other areas.
Type of
Document:
Website detailing innovative project that installs modules or human rights
offices within public health centers specializing in HIV/ AIDS care. It
addresses the need to provide guidance and advice on human rights to
people living with HIV, because of current mistrust towards protection
agencies and institutions responsible for law enforcement.
Audience
Intended:
PLHIV who have been discriminated against or experienced rights
violations can receive guidance, support in filing and tracking complaints,
and legal advice. The offices also carry out training activities in human
rights for community workers, through training workshops and skills
development.
Population
Experiencing
Stigma and/or
Discrimination:
PLHIV.
Stigma and/or
Discrimination:
Discrimination.
Assess and/or
Address:
Address.
Implementation: They are physical offices, attached to public health centers. Two are
currently in operation.
Comments: Mexico focus.
Link: http://www.letraese.org.mx/proyectos/proyecto-1/
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